CH 27 (WM) Flashcards
Define “managed care”. [2]
Managed Care aims to manage claim costs✓ while maintaining or even improving✓✓ access to quality healthcare services.✓
The system integrates the delivery and financing of healthcare✓✓ by providing the insurer with some control over the healthcare SPs through provider networks.✓✓
Describe the role of managed care. [1]
The role of managed care is to achieve a balance between keeping HC affordable✓✓, but also ensuring the quality of HC remains of a high standard.✓✓
Tip: AQ
What are the objectives of managed care interventions? [2.5]
- Reducing the cost of medical events.✓✓ ME
- Reducing the number of unnecessary medical services.✓✓ MS
- Ensuring that medical services are delivered in an
appropriate setting.✓✓ MS - Improving the quality of care provided.✓✓
- Ensuring that high-risk members are managed and receive appropriate care.✓✓
Describe how MC may result in an increase in cost of claims over time. [1.5]
There is a tendency for those covered by PMI to demand that the best healthcare services available are offered to them, whatever the cost may be.✓✓✓
This is exacerbated by the highly emotive aspect of healthcare, esp. for family members.✓✓
Very expensive treatments pose a risk to insurers if they are demanded by more and more PHs over time.✓✓
Define treatment protocols together with four examples. [5]
It is a set of guidelines✓ setting out the optimal sequencing of diagnostic testing and treatment for specific conditions.✓✓
It is important that MCOs✓ collaborate with recognized medical specialists✓ to develop credible and recognised protocols✓✓, based on clinical best-practice.✓
Examples –
* A restrictive formulary governing which medicines (likely to be mainly generic medicines)✓ may be used for certain conditions.✓✓
* A requirement for a GP referral to be obtained prior to visiting a specialist.✓✓
* Restricting access to a select network of specialists and GPs✓✓, with whom preferential charging structures have been agreed.✓✓
* Maternity program✓ – only allowing caesarean section where these are deemed clinically necessary by a HCP✓✓
Describe the need to develop treatment protocols and the considerations that should be taken into account during this process. [2.5]
- Managed care protocols need to be updated continually as new medicines and treatments are being made available.✓✓
- This is mainly due to technological advances and new disease emerging over time.✓✓
- They will also have to comply with the regulations insofar as they cannot unreasonably restrict access to healthcare for policyholders.✓✓
- The more restrictive a managed care is the higher the potential cost-savings.✓✓
- it is important that managed care organisations✓ collaborate with medical experts✓ to develop credible and recognised protocols, based on clinical best practice.✓✓✓
Outline how cost-effectiveness analysis is used in developing protocols.[3.5]
- Very often, cost-effectiveness decisions for medicines will be influenced by the results of international clinical trials.✓✓
- for treatments where the expected cost of prevention exceeds the costs of treatment✓✓, the benefit offered by these medicines is significantly greater than its costs✓✓, meaning their inclusion as part of medicine formularies is easily justified.✓
- Insurers would aim to minimise costs by restricting treatments and services included under treatment protocols.✓✓
- But it is also possible that very restrictive formularies may actually restrict access to quality healthcare.✓✓
- It is the role of legislation to ensure that managed care is not abused to unfairly exclude lives that need medical aid coverage✓✓, or to unfairly exclude access to required treatments✓.
Describe the risk of abuses in managed care protocols.[1.75]
- There is risk that managed care protocols can be abused beyond the aim of controlling healthcare costs.✓✓
- It is possible for some insurers to use managed care as a means to exclude relatively unhealthy lives.✓✓
- This is an abuse of managed care since the aim of managed care should be coverage of expensive treatments for diseases on an affordable basis✓✓, rather than the exclusion of lives with the respective disease.✓
State the disadvantages of treatment protocols.[3]
- Given the extremely complex nature of healthcare and vast diversity of diseases that exist✓✓, it is most likely that 1st time PHs will come to know the relevant protocols of their insurer is at the time of claiming for a certain condition.✓✓
- Many of those who have a claim declined✓, or having to make use of an alternative medicine or treatment than they would preferred, will be aggrieved.✓✓
- Protocols need to be updated continually, as new medicines and treatments become available due to technological advances, as well as new diseases emerging over time.✓✓✓
- Very restrictive formularies and protocols may actually restrict access to quality healthcare.✓✓
What are some of the legislative and regulatory requirements w.r.t. treatment protocols? [2.75]
- Regulators/legislation often require that protocols and formularies be made available to members and HCPs upon request to ensure transparency.✓✓
- Furthermore, protocols and formularies must be developed on the basis of evidence-based medicine✓✓, taking into account considerations of cost-effectiveness and affordability.✓✓
- Evidence-based healthcare refers to the use of appropriate medicines and techniques based on clinical research.✓✓
- It is the role of legislation to ensure that MC is not abused to unfairly exclude lives that need medical aid coverage, or to unfairly exclude access to required treatments.✓✓✓
List the measures that may be used in order to assess the quality of care. [1.5]
- Patient mortality rate ✓
- Specialist referral rate ✓
- Procedure complication rate ✓
- Hospital admission rate ✓
- Patient questionnaires ✓
- Chronic medication adherence ✓
Outline the questions that should be asked when determining whether the results of a clinical study should be considered when adjusting treatment protocols. [3.5]
- Are the results valid?✓✓ Did the study use appropriate research methods to value or measure the benefits?✓✓
- What are the results?✓✓ Do results show the test is more accurate or the treatment more effective?✓✓
- What is the sensitivity of the results✓ to changes in research subjects✓, treatment regiments✓ and medicine dosage✓?
- Are the results applicable to the targeted group of policyholders or patients?✓✓
Question 5.13
A medium-sized, short-term insurance company has decided to start writing a medical benefits policy that will cover payment of hospital fees, surgeons’ fees convalescence fees. It will be sold on an individual and group basis.
For each type of fee covered by the policy, describe a significant risk and how this could be controlled using managed care interventions.
[4]
Risks and how they may be controlled using managed care interventions Hospital fees
With hospital fees, there is a risk that policyholders will choose to be treated at the hospital that is perceived to be the “best”, which is also likely to be one of the more expensive hospitals to receive treatment at.
This risk could be controlled by using a hospital network. [1⁄2] [1⁄2]
Use of hospital networks would restrict treatments to selected hospitals with which a preferential charging structure has been agreed.
[1⁄2] This would reduce the costs of claims for the insurer. Surgeons’ fees
Similarly, with surgeons’ fees, one of the most significant risks is that policyholders want to be treated by the most popular surgeons, who are likely to be the most expensive.
[1⁄2] [1⁄2]
This risk could be controlled by using a specialist network of surgeons, which would operate in a similar way to the hospital network described above.
Convalescence fees
The most significant risk is that – as a result of the insurance being in place – a policyholder takes longer to recover from an illness, and so more medical intervention is required.
[1⁄2] [1⁄2]
To control this risk, the insurer could implement managed care protocols to ensure that only necessary convalescence fees are covered.
[1⁄2]
For example, the insurer could:
limit the number of days of hospital accommodation that is covered after the treatment has stopped (this would need to vary by illness)
[1⁄2]
restrict the number of follow-up treatments covered (eg physiotherapy sessions), with further sessions requiring individual approval.
[1⁄2]
[Maximum 4]
