Week 9: Managed Care Plans Flashcards
(36 cards)
Why managed care?
-national health expenditures keep rising
-19.3% of gross domestic product
-life expectancy keeps rising = more old people to spend money on care
Managed care
-approach to the delivery of healthcare services in a way that puts limited resources to best use in optimizing patient care
-increase outcomes while dec costs
-often used interchangeably with health plans
managed care points
-highly regionalized (insurance regulated by states)
-molded by territorial demands
-varied based on employer size
-used by both private and public health plans
MCOs include
-managed medicare and medicaid programs
-employer-offered commercial insurance plans
-department of defense TRICARE programs
-integrated delivery systems and ACOs
Focus of MCOs
-control cost by controlling supply and demand
-utilize array of cost management strategies to influence cost-effective decisions
History of managed care
-second half of 20th century: americans began to consider access to appropriate hc a right
-more pressure for more services
HMOs
-expanded w HMO act of 1973 (Nixon)
-promoted wellness! and health prevention! in addition to comprehensive acute and chronic care
-west cost and minnesota
-lowkey fell off, why:
-had to go to HMO providers, less choice but more choice in cities
-less incentive for company to invest bc employees aren’t gonna stay with the company forever
Goals of managed care
-prevent disease
-focus on wellness and enhances QOL
-improve clinical outcomes
-quality and accessibility of health care
-cost containment!!
MCOs
-generic term for manged care organization
-Health Maintenance Org (HMO)
-Preferred Provider Org (PPO)
-Point-of-service plan (POS)
-all may not conform exactly to any of these formats
-MCOs manage cost and utilization of covered services and products to optimize pt care through efficient use of limited resources
Accountable Care Orgs (ACOs)
-groups of doctors, hospitals, other HCPs
-voluntarilty work together to provide coordinated high-quality care to their Medicare or group insurance pt and accept financial risk/reward tied to clinical outcomes
-liscences governed and measured by Centers for Medicaid and Medicare services (CMS)
-newer practice, prob gonna see more often
-puts more pressure on providers to cut unnecessary care
-“if we save money, we get to keep money, but if it costs more, we still pay”
Preferred Provided Org (PPO)
-managed care delivery model consisting of preferred networks of providers w some out-of pocket network coverage
-offer more choice and flexibility than HMOs but higher premiums
-less out-of-pocket for pt to go in network, high deductible outside network
-if ER cost $250, bill will take off -$150 for going in network
Covered Pharmacy Benefit
-most MCOs offer Rx plan
-manage formularies, use utilization management, and cost-sharing to manage costs
-also use prior authorization, step therapy, quantity limits
-tiers/tiered formulary
-pharmacy benefit design that financially rewards patients for using generic and preffered drugs
-higher copayments for higher tiers
Tiers for Prescription Drugs
-1: no/low copayment - generic
-2: med copay, preferred brand-name drugs
-3: higher copay, nonpreferred brands
-4/specialty tier: highest copayment, very high cost brands
-tiers reward pt for using generic/prefered drugs
Other tier listed?
1: preferred generic
2. non-preferred generic
3. Preferred brand
4. nonpreferred brand
5. preferred specialty
6. nonpreferred specialty
-cost increases w tiers
Types of group insurance plans
-conventional: highest premium, few restrictions, not many left anymore
-HMO: managed care, restrictive, self-contained
-PPO: incentives to use certain facilities and providers, more expensive and more choices than POS plans
-POS: point of sevice, you choose between in and out-of network providers, pay less in network
-HDHP/SO: high deductible w savings options w PPO or POS elements, fastest growing
POS
-point of service managed HC plan
-allows you to choose between in network and out of network providers, pay more out of network
-better in cities
Distribution of Health plan enrollment
-growth in HMOs that fell off
-large growth in PPOs
-largest growth in HDHP/SO
-similar distribution between small and large firms
-small firms use a lil more POS
-large firms use a lil more HDHP/SO
-both use HMO the most
-employer premium contributions have been rising more than workers
-higher deductibles in small firms
-dramatic dec in conventional
-growth and fall in HMO
-largest growth in PPO
-POS dec
-highest growth HDHP/SO
-similar trends in small and large firms
-little more difficult for small firms to negotiate PPOs
-employer premium contributions have been rising more than workers (huge % of employer cost)
-higher deductibles in small firms
-cost for employers and employees has gone up
GLP-1 and spending
-all firms concerned about costs
-will impact smaller firms more
-only 18% cover GLP-1 for weight loss, mostly by larger firms
Drug rebates
-larger firms receive more drug rebates negotiated by PBMs as savings
Premiums stats
-premiums increasing
-employer contribution rising faster than workers
-family coverage increased more than single coverage (both inc by 4x in 20 years)
-family coverage way more expensive premium
-premium charges dramatically going up after 2003 but employers aren’t attracting employees with those so they started to go down a little bit
-the highest increases have been in deductibles (keep premium low, raise deductible)
How to pay for health care
-Health Savings Account (HSA)
-Health Reimbursement Arrangement (HRA)
-Flexible Spending Account (FSA)
Health savings account (HSA)
-tax-advantaged account used to pay for current and future healthcare expneses
-max $4300/yr (untaxed)
-can be used anytime
Health Reimbursement Arrangement (HRA)
-employer-funded account used to reimburse for eligible healthcare expenses
-must be used in calander year or forfeited
Flexible Spending Account (FSA)
-deduct pre-tax $ from paycheck for eligible expenses
-max 4300/yr
-must be used in calander year or forfeited
-can have separate accounts for med, or child expenses
