Exam 1 review Lecture 1-2 Flashcards
1
Q
Healthsystem stakeholders: The Five P’s:
A
- patients
- purchasers
- payors
- providers
- pharmaceutical manufacturers and othe suppliers
2
Q
Examples of Purchasers
A
- government
- employers
- consumers
3
Q
Examples of Payers
A
- health insurerers(Medicare,Medicaid)
4
Q
Examples of providers
A
- physicians
- pharmacists
- hospitals
5
Q
Health policy
A
- a set of decisions or commitments to pursue courses of action aimed at achieving defined goals of improving health
- values of stakeholder organization
- policies should specify the source of funding that can be applied to planning and implementation of policy and to relevant institutions involved in the process
6
Q
Total National health expenditures
A
- Hospitals = 31%
- Other health = 27%
- Physicians and clinics = 20%
- Rx drugs = 8%
7
Q
Charge
A
- what the provider charges for the medical product or service (or prescription drug, as is the case for pharmacies)
8
Q
cost
A
- what the product or service actually costs the provider
9
Q
Reimbursement
A
- what the provider gets paid for the product or service
- comes from health plan and patient (through their co-payment or deductible)
- typically negotiated with a health plan
- should be higher than cost but is typically much lower than charges
10
Q
Payment mechanisms for hospitals
A
- fee-for-service (FFS)
- discounted FFS
- diagnosed related group (DRG) = case rate
- per diem payments
- Accountable Care organization (ACO)/capitation or bundled payments
11
Q
Per Diem (Per Day) Payments
A
- hospitals gets one fixed payment for each day in the hospital
- may differ for different units:
= routine patient day
= ICU
= telemetry/step-down unit
= observation
= rehabilitation
= Etc.
12
Q
Fee-For-service
A
- do more, keep longer
13
Q
DRG (case rate)
A
- do less, keep shorter
14
Q
Per Diem
A
- do less, keep longer
15
Q
Payment for mechanisms for outpatient physician care
A
- FFS
= private insurance plans: UCR (Usual, Customary, Reasonable)
= Health plans typically negotiate with providers to get a discounted UCR
= Medicare: Medicare RBRVS (Resource Based Relative Value Scale) - Capitation (typically used for primary care)
- Case rates/episode of illness payments/bundled payments
16
Q
How does Medicare for Outpatient Services: RBRVS?
A
- pay physicians for services based on submission of a claim using one or more specific CPT codes
- each CPT code has Relative Value Unit (RVU) assigned to it which, when multiplied by the cost conversion factor (CF) and a geographical adjustment (GCPI) factors, creates the compensation level for a particular service
- moving toward Value-based payment– MACRA and MIPS
17
Q
Medicare Geographical Adjustment (GCPI) Factors
A
- provide work RVU
- Practice Expense RVU
- Malpractice RVU
18
Q
Provider work RVU
A
- the relative level of time, skill, training and intensity to provide a given service
19
Q
Practice expense RVU
A
- component addresses the costs of maintaining a practice including rent, equipment, supplies and non-physician staff costs
20
Q
Malpractice RVU
A
- are generally the smallest component of the RVU values and represent payment for the professional liability expenses
21
Q
The changing face of physician payment under Medicare: MACRA
A
- Medical Access and CHIP Reauthorization Act of 2015
- Moves toward “value” from “volume”
- 2 main pathways for physician payment:
1) Alternative payment models (APM’s) (such as case rates)
2) Merit-based incentive payment system (MIPS) — payment adjusted based on quality and value
22
Q
how do other plans (non-Medicare) pay physicians?
A
- similarly use a fee schedule that has been negotiated or presented to the provider
- fee schedule may be based on the Medicare fee schedule (ex: Medicare +5%, Medicare +10%)
- providers may be offered additional incentive payments for quality, heath IT (EMR) system, extended hours, e-mail, or other services
- primary care providers may be paid capitation (fixed payment per head in the patient panel, per month, demographically adjusted)
- some providers MAY be paid case rates rather than FFS for specific service episodes
