Exam 1 - Powerpoint 4

Question 1

ACA push toward universal coverage

Answer 1

Health insurance market reform
Individual coverage mandate
Employer-sponsored coverage
expansion of Medicaid 133/138% FPL <65
Exchanges/Marketplace subsidies 100-400% FPL

Question 2

Health insurance exchange

Answer 2

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

Question 3

Regulations for plans

Answer 3

Cover essential health benefits
Four levels of coverage
Out of pocket limits
Offer a catastrophic plan

Question 4

4 levels of coverage

Answer 4

Bronze - 60% coverage
Silver = 70% coverage
Gold = 80% coverage
Platinum = 90% coverage

Question 5

Catastrophic plan

Answer 5

for people up to 30, only covers catastrophic phase, OOP up till that

Question 6

Premiums vary on

Answer 6

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

Question 7

Regulations for ALL private health insurance plans

Answer 7

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

Question 8

Regulations for NEW private plans

Answer 8

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

Question 9

Essential Health Benefits

Answer 9

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.

Question 10

Individual mandate

Answer 10

began 2014

Pay insurance or $695 per adult, 2.5% household income penalty

2017 trump made the penalty $0

exceptions exist

Question 11

Medicaid expansion

Answer 11

Expanded to 133 / 138% FPL

Federal gov pays most (90%) of public costs for Medicaid expansion

Question 12

Employer requirements

Answer 12

> 50 have to provide insurance, or also penalty

Question 13

ACA timeline

Answer 13

Passed and signed 2010
Most things went into affect 2014, some immediately 2010
Donut hole closure was gradual 2010 - 2020

Question 14

ACA court challenges

Answer 14

Individual mandate
Medicaid expansion
Premium subsidies on exchanges
Cost sharing subsidies on exchanges
Contraception coverage mandate

Question 15

NFIB et al v. Sebelius

Answer 15

1st case against ACA to reach Supreme Court

Decided:
Individual mandate is OK
State can decide whether or not to expand Medicaid

Question 16

important legal challengers to ACA

Answer 16

Lawsuit targeting ACA premium tax credits (premium subsidies)

Lawsuit targeting ACA cost-sharing subsidies

Lawsuit targeting ACA requirement for free contraceptive coverage

Question 17

Death Spiral

Answer 17

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

Question 18

HMOs/ Managed care

Answer 18

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

Question 19

HMO Act of 1973

Answer 19

Dual choice mandate = large employers that offered traditional insurance (FFS plan) had to also offer HMO alternative
expired in 1995

Question 20

Staff model HMO

Answer 20

MDs serve as salaried employees
MDs work in HMO-owned building
MDs do not see patients not enrolled in HMO

Question 21

Group Model HMO

Answer 21

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

Question 22

Open-Panel or Network Model HMO

Answer 22

Based on contracts with IPAs
IPAs contract with MDs

Independent Practice Associations, MDs wanted alternative that would let them remain more independent

Question 23

Key HMO characteristics

Answer 23

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

Question 24

“backlash” against HMO

Answer 24

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.

Question 25

Preferred Provider Organization

Answer 25

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

Question 26

Point of Service plan

Answer 26

hybrid HMO and PPO

Question 27

PPOs and POS issue

Answer 27

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

Question 28

Accountable Care Organizations

Answer 28

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

Question 29

Financial incentives ACO

Answer 29

shared savings and potential losses

incentivized lower spending and improve/maintain quality

All ACOs accept upside risk, some accept downside risk

Question 30

How is quality measure ACOs

Answer 30

track performance on quality of care using specific benchmark measures

claims data
Survey patients
electronic medical record data

Question 31

PCMHs and ACOs take home

Answer 31

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

Question 32

Pharmacist roles in PCMHs and ACOs

Answer 32

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

Question 33

Bundled payments

Answer 33

Knee replacement, “bundle” include pay for surgeon, hospital charges, rehab etc

Question 34

Benefits of Bundled payments

Answer 34

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.

Question 35

Downside of Bundled payments

Answer 35

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