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Healthcare Systems Year 1 Term 1 > Health Care Policy > Flashcards

Health Care Policy Flashcards

1
Q

What are the primary changes made by the Federal Government with regards to Heatlhcare from Affordable Car Act?
(7)

A

Focused on Medicare

  • Increased preventative care
  • Closed Part D coverage gap
  • began testing delivery programs
  • Increased the number of beneficiaries who pay higher premiums
  • Changed payment structure to Medicare Advangtage plans
  • Decreased payment for hospital infections and re-admissions
  • Pilot of bundled payment
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2
Q

Federal government increase funding for
_______(100% of the cost through
2016), )______, and those eligible for ____________ with the affordable care act

A

Medicaid, CHIP, and those eligible for subsidies through the exchage

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3
Q

Variety of institutes/boards have been created. Focus on _____,______, and ________ in the affordable care act

A
  • improvinghealth care quality
  • increasing coordination between institutions
  • testing delivery methods
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4
Q

At the onset of the ACAin 2012, CMS began a 3-year demonstration program to assess impact of quality measure reporting and
plan rating on delivery of care.
What were the aims of this?
(2)

A

Encourage plans to improve with star rating

To see if providing bonues will lead to more rapid and better improvements in Medicare Advantage programs.

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5
Q

The ACA allowed Medicare Advantage Plans to create a way to compare plans? What was this?

A

Marketplace for health plan comparison using info from consumer and payer (the insurance)

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6
Q

ACA created what type of scale is used to rank plans?

A

Five point scale used to score plans on

the level of quality provided

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7
Q

Where are ratings for Medicare found?

A

On CMS website

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8
Q

What did the ACA allow CMS to do?

3

A
  • Calculate bonus payments
  • Determine enrollment eligibility
  • Beginning this year, penalties for plans that have performed poorly for > 3 years (administrative holds, shut down)
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9
Q

How does the ACA bonus system work for 5 Star Medicare plans?

A

Five star plans submit bids that are less than the benchmark, but the benchmark for those plans is 5% higher than most plans. Insurance plans get the difference of the plan cost and the benchmark, so 5 star plans are able to make 5% more than other plans just for being cool.

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10
Q

ACA is allowing CMS to reduce payments with excessive re admissions
Based on 30 day re admissions to any hospitals for any reason
What does this mean?

A

Based on degree of readmission of surgeries or complications after them, it will reduce reimbursement up to 2% on all payments

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11
Q

What are the two things that States are now allowed to do under the Affordable Care Act?

A

States have the ability to administer Health Insurance Marketplace

States may decide on whether to accept federal money for expanding their Medicaid
programs.

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12
Q

For states that do not offer Insurance Marketplaces what can people do?

A

Use the federal exchanges

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13
Q

What happens if States accept federal money?

Most importantly…

A
  • they must comply with ACA dictated Medicaid changes

- Most importantly expand eligibilty to 138% the federal poverty line

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14
Q

What was the Oregon Medicaid Experiment?

A

A expansion that provided coverage to 20,000 individuals via a lottery system. Data was
collected on health outcomes and utilization.

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15
Q

What are reasons to support insurance expansion?

based on Oregon Health Plan

A

Improved self-reported health, reduced
financial strain, increased diagnosis of
depression

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16
Q

What are reasons to oppose insurance expansion?

based on Oregon Health Plan

A

No improvements in objective measures (hypertension, diabetes, high cholesterol), increased emergency department visits

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17
Q

What are some restrictions placed on insurers from Affordable Care Act?
(with regards to pre-existing conditions, rescission, health status)

A
  • No longer deny coverage for pre-existing conditions
  • No longer end coverage when policyholders get sick (rescission)
  • No longer charge higher premium based on current/projected health status
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18
Q

What are some restrictions placed on insurers from Affordable Care Act?
(with regards to waiting periods and dependents on parents plans)

A
  • Waiting periods are capped at 90 days

- Allow dependents up to aged 26 on parents’ policy

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19
Q

What are some restrictions placed on insurers from Affordable Care Act?
(with regards to deductible limits, lifetime limits)

A
  • Deductible limits (individual/family): $2,000/$4,000; Total out-of-pocket limits: $6,350/$12,700
  • No annual or lifetime benefits limits
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20
Q

What are some restrictions placed on insurers from Affordable Care Act?
(with regards to essential health benefits)
Who enforces these rules?

A

-Insurer’s must cover “essential health benefits” and may not require co-pays/deductibles for preventative services

(defined as Level A or B by the US Preventative Services Task Force)

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21
Q

What is a medical loss ratio?

A

is the percent of premium an insurer spends on claims and expenses that improve health care quality.

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22
Q

What are some restrictions placed on insurers from Affordable Care Act?
(with regards to Medical loss ratios?)

A

Insurers must keep their medical loss ratios(Chapter 2) at 85% (large groups) or 80% (small group)

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23
Q

What are the three classifications for employers under the ACA?

A

Small (Under 50)
Large (51-200)
Very Large Employers (greater than 200)

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24
Q

How did the ACA effect small employers?

A
  • Receive tax credits if they offer insurance and will be allowed to purchase insurance (group policy) through the Small Business Health Options Program (SHOP) (marketplace)
  • Apply for grants to establish employee wellness programs
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25
Q

How did the ACA effect large employers?

A

Required to offer affordable health insurance options. “Affordable” defined as less than 8% of any full time employee’s income (penalties begin in 2016)

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26
Q

How did the ACA effect very large employers?

A

Must automatically enroll employees in the company’s health insurance plan. Employees may opt out. Monetary penalties begin in 2016.

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27
Q

How did the ACA effect Individuals?

2

A

Easier for individuals to acquire and afford insurance

28
Q

How did the ACA make it easier for individuals to acquire Insurance?

A

Changes to the insurer regulations and development of marketplaces

29
Q

How did the ACA make it easier for individuals to afford Insurance?

A
  • Individuals purchasing through the exchange who make less than 400% of the federal poverty line.
  • Also includes Medicaid expansion and small employer subsidies
30
Q

What are marketplaces with regards to the ACA?

A

attempt to make health plan comparison easier

31
Q

What do the insurance marketplaces do?

5

A
  • Rating system
  • Actuarial value of plans
  • Standardization of co-payments, co-insurance, and -deductible on certain services
  • Website link to the full explanation of benefits
  • Written in “plain language”
32
Q

Star Ratings what are consumer perceptions?

A

Not to good. People dont believe a five star plan is something they can afford.

33
Q

What happens to people who do not purchase health insurance? ACA

A

They pay a penalty

34
Q

What is the penalty people pay who don’t have health insurance? ACA

A
  • Start: $95 per adult/$47.50 per child or 1% of income
  • Finish: $695 per adult/$347.50 per child or 2.5% of income (whichever is greater) and then increase with cost-of-living adjustments
35
Q

Who is exempt from paying the ACA penalty?

A

Financial hardship, religious objections, American Indians, uninsured for 3 months or less, incarcerated

36
Q

How many people are uninsured after the ACA?

A

30 million people will still be uninsured after the ACA.

37
Q

Reasons for not having coverage after ACA?

5

A
  • Undocumented immigrants
  • Financial hardship (any plan costs more than 9.5% of income)
  • Select groups are except from the individual mandate –religious objections, American Indians, “short coverage gap” exception
  • Those with an income of less than 138% of the FPL, but live in a state that did not expand Medicaid
  • Chose to pay the tax penalty rather than buy insurance
38
Q

What are the three types of Reimbursement models?

A
  • Services Rendered
  • Defined Criteria
  • Pay for performance and value based purchasing
39
Q

What is services rendered reimbursement?

A

Fee for service

40
Q

What can defined criteria reimbursement be?

3

A
  • Per diagnosis: DRG or bundled payment
  • Per patient: capitation
  • Per year: salary (physician), global budget (hospital)
41
Q

What is Pay for performance and value based purchasing?

A

Global terms for reimbursement based on measures of clinical quality, safety, efficiency, and patient satisfaction

42
Q

What is the big picture of Value based reimbursement?

2

A

Volume driven care is seen as expensive and poor quality

Value drive care is seen as way to make it cheaper and better quality.

43
Q

How are insurance programs measured for quality?

A

National measurement programs.

44
Q

What do national measurement programs do?

Examples? (5)

A

reflect different dimensions of plan performance and health outcomes

HEDIS (Healthcare Effectiveness Data and Information Set)
CAHPS (Consumer Assessment of Healthcare Providers and Systems)
HOS (Health Outcomes Survey)
National Committee of Quality Assurance (NCQA)
Medicare Star Ratings

45
Q

Where are Medicare Advantage Plan Ratings derived? (4)

A
  • CMS administrative data on plan quality and member satisfaction
  • Consumer Assessment of Healthcare Providers and Systems (CAHPS)
  • Healthcare Effectiveness and Data and Information Set (HEDIS)
  • Health Outcomes Survey
46
Q

How is the score for Medicare Advantage plans derived? (3)

A

Health services –> 36 topics in 5 categories
Drug services –> 15 topics in 4 categories
Health & drug services –> All topics above (48 in total)

47
Q

How can a clinical pharmacy show value?

A
  • Quality measures
  • Clinical outcomes
  • Medication Reconciliation
  • Billing
48
Q

What is important to know about ways clinical pharmacy can show value?

A

sometimes methods overlap and sometimes they function independently

49
Q

What is the Pharmacy Quality Alliance?

A

Non-profit representing an alliance of > 130 member organizations including health plans & pharmacy benefit managements, professional pharmacy associations, federal agencies, pharmaceutical manufacturers, and consumer advocates.

50
Q

What is a pharmacy benefit manager?

A

a pharmacy benefit manager (PBM) is most often a third party administrator (TPA) of prescription drug programs but sometimes can be a service inside of an integrated healthcare system (e.g.: Kaiser or VA). They are primarily responsible for processing and paying prescription drug claims.

51
Q

What is the mission of the Pharmacy Quality Alliance?

A

Improve the quality of medication management and use across health care settings with the goal of improving patients’ health through a collaborative process to develop and implement performance measures and recognize examples of exceptional pharmacy quality.

52
Q

What are the five measures taken from those created by the Pharmacy Quality Alliance (PQA)?

A

2 keys

  • Medication safetty
    1. High risk medications in elderly
    2. Appropriate treatment of blood pressure in patients with diabetes
  • Medication adherence
    1. Oral anti diabetic meds
    2. Cholesterol meds
    3. Anti-hypertensive agents
53
Q

What do these measures do?

A

They basically encourage pharmacists to decrease high risk meds, make sure people get appropriate treatment, take their meds right
In theory will save everyone money and make people money too.

54
Q

Accountable Care Organization (ACO)

A

is a “medical neighborhood” that include primary care providers, specialty providers, and hospitals. They coordinate patient care within an integrated infrastructure and emphasize primary care.

55
Q

What is a CCO?

A

Coordinated Care Organization

56
Q

What is Oregon doing in regards to CCOs?

A

Oregon is tracking 17 CCO incentive metrics and 16 additional state performance metrics

57
Q

Why is Oregon tracking CCOs?

What should be noted?

A

Determine if CCOs are effectively and adequately improving care, making quality care accessible, eliminating health disparities, and controlling costs.
*Seem to be meeting metrics

58
Q

MEDICAL PRACTICE REALITIES… (time and patients)

A

Practitioners often have 2500 hundred patients, not enough time in a day.

59
Q

What has been done to improve efficiency?

A

Use specialists and pharmacists with technicians to improve care.

60
Q

What is the result of more efficiency in the clinical setting?

A

Transition of Care

61
Q

What is Transition of care?

A

The movement of a patient from one setting of care (hospital, ambulatory primary care practice, long-term care, home health, rehabilitation facility) to another

62
Q

What is the goal of transitions of care?

A

Goal: Reduce 30 days re-hospitalization by reimbursing for care management and care coordination

63
Q

What does transition of care look like compared to traditional care?
What is this trying to take advantage of?

A

Patients will see multiple specialists, pharmacists, nurses, doctors, and recieve phone calls to improve medication adherence
-More people more billing opportunities

64
Q

What is the benefit of adding a pharmacist to the transition of care?
(3)

A

Addition of a pharmacist to the TOC clinic –(1) decreases physician time spent with patient, (2) increases the billable value of the visit (RVU), and (3) decreases re-hospitalizations (30 day: 9% vs 26%; 90 day: 19% vs 44%)

65
Q

What has expanded pharmacists roles?

A

Provider Status Bill amends section 1861(s)(2) of the Social Security Act to include:
Pharmacists services under Medicare Part B
•These services would be reimbursable if provided in areas defined as (1) medically underserved, (2) medically underserved population, or (3) health professional shortage areas

66
Q

What does a pharmacist as a provider allow?

A

Movement from fee-for-service –> New payment systems

SSA remains reference point, more power in time.

Healthcare Systems Year 1 Term 1 (7 decks)

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