final Flashcards
payment function has 2 facets
- determine methods and amounts of reimbursement in advance of the delivery
- actual payment after services rendered
adverse selection
when high risk patients enroll in large numbers compared to healthy -> causes premiums to raise for everyone
-current direction and issue
cost shifting
- used to make up for revenue shortfalls -> providers charge extra to payers that don’t exercise strict cost controls
- current issue and direction
case mix
- mutually exclusive and differentiate patients according to the extent of resource use
- prospective
premium risk rating
community rating- spreads the risk among the group
experience rating- different risks different rate
adjusted community rating- combination- prices are changed based on age, gender, geography…ignore other risks
balanced budget act of 1997
- The Medicare Payment Advisory Commission (MedPac)- advises US Congress on issues affecting Medicare through analysis of payments to providers participating in Medicare, access, and quality.
- Medicare Rural Hospital Flexibility Program (MRHFP)- a rural hospital can file for an application with Medicare to be classified as a critical access hospital (CAH). The requirements are that there must be no more than 25 acute care and/or swing beds, must provide 24-hour emergency services, and must be a certain distance away from other hospitals(receive cost-plus reimbursement -> not prospective)
- Children’s Health Insurance Program (CHIP)- Joint state and federal program established by title 21 of social security act under Balanced Budget Act of 1997
- Gave states authority to implement mandatory managed care programs without required federal waivers -> medicaid grew rapidly
- Reduced payments to HMO through Medicare causing HMOs to drop out and people lost benefits
WHO Primary Health Care
- Point of entry- gatekeeper
- Coordination of care- ensure continuity and comprehensiveness
- Essential care
Institute of Medicine Primary Health Care
- Comprehensively addresses any health problem at any stage of a patient’s life
- Coordination ensures a combination of health services to best meet the patients needs
- Continuity of care administered over time
- Accessibility
- Accountability
Growth in Outpatient Care
- Reimbursement- more reimbursement for outpatient because it incentives less hospital crowding (costs less for insurer)
- Technological factors- less invasive procedures -> pts go home quicker and recover
- Utilization control factors- managed care restrictions on utilization, quicker discharge, prior authorization (precertification), utilization review, list of hospitals that you are covered for
- Physician practice factors
- Social factors- preferred to have health care at home or community setting, more personal
- Fewer payment restrictions- surgery, dialysis, chemotherapy are all fee-for-service
hospital transformation in the United States
- social welfare- Almshouses and pest houses
- care for the sick- Public and voluntary (charity) institutions
- medical practice- medical science and technology, hospital administration, organization, efficiency, the joint commission
- medical training and research- collaboration between hospitals and universities
- consolidated systems- organizational integration, service diversification, hospital/healthcare systems*
community hospital
- local or state NOT federal
- short stay
- serve general public
noncommunity hospital
- federal
- prisons, colleges…institutions
- long term stay
medical staff
- head of medical staff is chief of staff
- chief of services are head of their specialties
cost control in managed care
- choice restriction
- care coordination
- disease management
- pharmaceutical management
- utilization review
- practice profiling
cost control in managed care: care coordination
- gatekeepers
- case management
cost control in managed care: practice profiling
Evaluates provider-specific practice patterns and compares it to a norm. Feedback is provided to change behavior. Improves quality and efficiency
state legislature statutes for managed care
- Any Willing Provider- Requires admission of any provider into a network as long as the terms and conditions of the network are abided by.
- Freedom of choice- Require MCOs to allow their enrollees to seek care from providers outside the panel and not be penalized for it
- reduces quality and increases cost
prospective UR
-Gatekeeper decision to refer or not
-Preauthorization (precertification) guidelines for hospitalization and assign initial length of stay
-Informs concurrent review about the case in order to monitor and additional days of care can be authorized if necessary
-For pharmaceuticals:
formularies are the first step
preauthorization for certain drugs and biologics
HMO staff model
- employ physicians on salary
- contracts for only uncommon specialties and hospital services
- pros:
- exercise control over physicians
- convenience of one stop shopping
- cons:
- fixed salary expense can be high
- expansion into new markets is difficult
- limited choice of physicians
HMO group model
- contract with a single multispecialty group practice separate hospital contracts
- group practice is paid a CAPITATION
- pro:
- no salary or facility expenses (as in staff model)
- well known practice may lend prestige
- cons:
- difficulty with service obligations if a contract is lost
HMO Network model
-contract with more than one group practice
-capitation
-variations:
-contracts with only PCPs who are financially responsible for specialty services,
or,
-separate contracts with PCPs and specialists
-pros:
-wider choice of physicians
-cons:
-dilution of utilization control
HMO IPA Model
- separate entity from the HMO
- capitation
- HMO contracts with IPA (independent practice association)
- IPA (not HMO) contracts with providers
- pros:
- eliminates the need to contract with various providers
- transfers financial risk to the IPA
- choice of providers *
- cons:
- difficulty with service obligations if a contract is lost
- dilution of utilization control
- generally, a surplus of specialists
