Exam 1 - Powerpoint 4 Flashcards
ACA push toward universal coverage
Health insurance market reform Individual coverage mandate Employer-sponsored coverage expansion of Medicaid 133/138% FPL <65 Exchanges/Marketplace subsidies 100-400% FPL
Health insurance exchange
online marketplace with info to choose
Run by states or gov on behalf of state
Premium subsidies 100-400% FPL, Cost-sharing subsidies 100-250% FPL
Regulations for plans
Cover essential health benefits
Four levels of coverage
Out of pocket limits
Offer a catastrophic plan
4 levels of coverage
Bronze - 60% coverage
Silver = 70% coverage
Gold = 80% coverage
Platinum = 90% coverage
Catastrophic plan
for people up to 30, only covers catastrophic phase, OOP up till that
Premiums vary on
age (3 to 1 ratio)
geographic area
tobacco use (1.5 to 1)
number of family members
Cannot charge people more due to health status
Regulations for ALL private health insurance plans
not deny enrollment for any reason, including health status
Not drop people from coverage, unless fraud
Not have lifetime limits on coverage
Allow young adults to stay on parents until 25
Devote 80% of premiums to medical costs
Regulations for NEW private plans
Not deny coverage for treatment of pre-exisiting conditions
Not impose waiting periods over 90 days
No annual caps on coverage
Specified preventative services for free
Submit any premium increase to gov for review
Limit annual OOP costs
Essential Health Benefits
Ambulatory patient services
Emergency services
Hospitalization
Maternity and newborn care
Mental health, subspace abuse, etc
Prescription Drugs
Rehabilitative and habilitation services and devices
Laboratory services
Preventative and wellness services and chronic disease management
Pediatric services, include oral and vision.
Individual mandate
began 2014
Pay insurance or $695 per adult, 2.5% household income penalty
2017 trump made the penalty $0
exceptions exist
Medicaid expansion
Expanded to 133 / 138% FPL
Federal gov pays most (90%) of public costs for Medicaid expansion
Employer requirements
> 50 have to provide insurance, or also penalty
ACA timeline
Passed and signed 2010
Most things went into affect 2014, some immediately 2010
Donut hole closure was gradual 2010 - 2020
ACA court challenges
Individual mandate Medicaid expansion Premium subsidies on exchanges Cost sharing subsidies on exchanges Contraception coverage mandate
NFIB et al v. Sebelius
1st case against ACA to reach Supreme Court
Decided:
Individual mandate is OK
State can decide whether or not to expand Medicaid
important legal challengers to ACA
Lawsuit targeting ACA premium tax credits (premium subsidies)
Lawsuit targeting ACA cost-sharing subsidies
Lawsuit targeting ACA requirement for free contraceptive coverage
Death Spiral
when insurance scheme collapses and fails.
health people don’t sign up, and only sick people do then premiums go up. premiums going up scares away more health people. sick people still need coverage so premiums go up more and more, never ending cycle
HMOs/ Managed care
defined pop and prepaid per capita $ to provider
large pool of mostly health people protects fewer, unlucky sick and injured
First appeared 1930s - 1940s, Henry Kaiser and Dr. Garfield
Early HMOs were salaried staff models
HMO Act of 1973
Dual choice mandate = large employers that offered traditional insurance (FFS plan) had to also offer HMO alternative
expired in 1995
Staff model HMO
MDs serve as salaried employees
MDs work in HMO-owned building
MDs do not see patients not enrolled in HMO
Group Model HMO
MDs not hired directly by HMO
HMO pays MD group in bulk, for care of enrollees
MD can only see patients enrolled in HMO contracted to them
Open-Panel or Network Model HMO
Based on contracts with IPAs
IPAs contract with MDs
Independent Practice Associations, MDs wanted alternative that would let them remain more independent
Key HMO characteristics
patients need referral from their assigned PCP to see other providers and specialists
In-network cost sharing is modest
Minimal coverage of services outside of HMOs providers
“backlash” against HMO
perverse incentives to skimp on care
big savings in early years but less savings over time
MDs and hospital didn’t like reduced payments, utilization reviews, panel restrictions, referrals.
Preferred Provider Organization
Most flexible and most popular, no need to choose PCP
Choose MDs from preferred providers list at low cost sharing
Choose MD from out of network, higher cost sharing
MD like to be on preferred list
Point of Service plan
hybrid HMO and PPO
PPOs and POS issue
don’t have a strong gatekeeper
Freedom improves patient satisfaction, harder to keep savings and costs down.
emphasis is mainly on cost reduction, not coordination of care, patient outcomes or quality
Accountable Care Organizations
entities that come together to form an integrated system with goal of taking shared responsibility
can include specialty MDs, hospitals, pharmacies etc
ACOs in Medicare are only for part A and B
Financial incentives ACO
shared savings and potential losses
incentivized lower spending and improve/maintain quality
All ACOs accept upside risk, some accept downside risk
How is quality measure ACOs
track performance on quality of care using specific benchmark measures
claims data
Survey patients
electronic medical record data
PCMHs and ACOs take home
exist outside of Medicare
Directly encourage by ACA
They try to use big data, enhance care, engage patient in own care, use Health IT and care management
Pharmacist roles in PCMHs and ACOs
medication management to improve adherence and outcomes
Drug therapy management and adherence clinics
drug utilization reviews
specialty pharmacy
provide preventative care services like immunizations, screenings, counseling, etc
Bundled payments
Knee replacement, “bundle” include pay for surgeon, hospital charges, rehab etc
Benefits of Bundled payments
patient may experience better outcomes to to incentive to avoid costly complications and readmission
patient may prefer lower-cost post-care setting such as home.
Downside of Bundled payments
Providers may have incentive to stint on care, avoid sicker patients since exceed target cost amount, could steer patients to affiliated facilities that are inconvenient or lower quality
