hpm 211 Flashcards
Federally Qualified Health Centers
Relies on hrsa
Receives cost-based, enhanced reimbursement from Medicaid
HRSA Criteria:
Serves in a medically-underserved area or serves a medically-underserved population (low-income urban, rural, HIV+, migrant workers, LGBT, etc.)
Governing board at least 51% patients
Non-profit or public
Takes all patients, regardless of ability to pay / immigrant status
DSH payments:
- Federal funds provided via Medicaid & Medicare to help hospitals caring for a disproportionate share of low-income and publicly-insured patients
- States decide how to disperse to qualifying hospitals: mostly non profit hospitals
Safety net definition:
Providers who either by legal mandate or explicitly adopted mission they maintain an ‘open door,’ offering access to services for patients regardless of their ability to pay;
Vulnerable populations/ why they matter
defined by race/ethnicity, socio-economic status, geography, gender, age, disability status, risk status related to sex and gender, and other populations identified as at-risk for health disparities.
They matters because of how policy impacts the population/definition
Voltage Drop Barriers to care from Eisenberg and Power
- The different voltage drops subset/transition into the next
-Ensuring high-quality health care requires that each of these “voltage drops” be recognized and addressed.
Who lacks health insurance:
40 million uninsured pre aca
This number drops to 25 million after ACA
Insurance coverage by age:
-65+ is more covered because of medicare
- children because of chip
- Non-elderly childless-adult lacks coverage
Independent risk factors for being uninsured:
income, citizenship, age, education level, race/ethnicity
Causes of uninsured status:
affordability, cultural barriers, lack of knowledge, eligibility for public programs
Churning
- transition between different types of coverage and/or becoming uninsured.
- More gaps in non expansion states due to churning
What does insurance do:
- Strong evidence that it improves financial burden, care access, and utilization.
- Fairly good evidence that it impacts health and mortality. Bens paper shows that theres a 3% decline statewide
- Expanding health insurance does impact health disparities that are related to insurance status
Insurance does not:
-Expanding health insurance will not save us money
-Does not impact large health disparities
Oregon health insurance experiment:
-study showed that Medicaid coverage generated no significant improvements in measured physical health outcomes (no statistically significant change in diabetes control, cholesterol, or blood pressure)in the first 2 years,
-but it did increase use of health care services, raise rates of diabetes detection and management, lower rates of depression, and reduce financial strain.
Kosnick paper on insurance impacts:
Study showed no mortality impact of health insurance
Sommers paper on insurance impacts:
3% decline in mortality statewide (esp in low-income counties and for health-care amenable causes)
- improvements in self-reported health, usual source of care, and physician’s visit in past year
Pre aca medicaid requirements:
Low Income and some other eligibility category - disabled, pregnant,
Post ACA mediciad:
-ACA took away the categorical requirements.
-Expanded to all citizens up to 138 FPL.
Medicaid expansion in 2023:
40 states expanded, 1 pending, 10 states have not expanded and it is an equity issue across states
medicaid expansion status in 2014
23 states did not expand, 26 did, 2 maybes
Coverage gap for non expansion states:
The options are Medicaid or marketplace; but there is a gap inbetween
-In states that didn’t expand, there is a coverage gap for childless adults. 44% -100% fpl do not have a place to get coverage
Medicaid benefits:
Medicaid is the Only payer for long term care. Medicare does not.
Federal requirements: outpatient, inpatient, ER, maternity, and long-term care
Federal limits on cost-sharing (5% income)
Optional benefits: drugs (though all states offer), vision, dental, medical equipment
Section 1115 wavers
trial periods for new things to add on to medicaid coverage
- experimental, pilot, or demonstration projects
- Approved by CMS for 5-year periods
Medicaid managed care:
private payer gets capitated funds from state to provide coverage
Per member per month payment to private payer
Now covers 70% of beneficiaries
Studies on medicaid mcos are mixed:
MCO state pros/cons
State Pros: budget predictability, improve incentives for cost containment, delegate to private sector
State Cons: resources spent on selection and overhead
MCO Beneficiaries pros/cons
Beneficiaries pros: focus on preventive care, oversight and care coordination
Beneficiaries cons: limited provider networks, inexperience of private plans in caring for the Medicaid population
Medicaid take-up with ACA
Take up of medicaid is not 100% even with aca
86% of children, 62% of eligible adults
Medicaid Churn
- Persists regardless of what coverage besides medicare
- 28% of children leave medicaid after a year, 50% of adults leave after 2 years
Medicaid churn causes and solutions
Causes: Variable incomes (Medicaid calculates monthly), multiple programs (CHIP/Medicaid), intentional cost saving policies
Solutions: Guaranteed 12 month coverage, less onerous renewals, automated processes, integrate systems (CHIP/Medicaid)
Medicaidchallenegs - causes and solutions to access to care -
Patient side:
Causes: transportation, language barriers, competing life priorities, no physician will take insurance
Solutions: wrap around services, physician workforce diversity
Access to care - Provider side:
- Pay all providers more
- Pay certain providers more
- ACA increased Medicaid primary care to Medicare rates for 2013-2014 – most states didn’t continue this
Where can states cut medicaid when budgets are tight?
Provider reimbursement, Payment to MC plans, Optional eligibility groups, Optional benefits (vision, dental, transport, etc.)
Changes under ACA
New insurance regulations - adults 26 stay on/ adds healthier individuals to risk pool
Eliminates pre-existing condition exclusions
Eliminates lifetime or annual limits on benefits
Premiums based only on age/smoking status (not gender)
No cost-sharing for certain preventive visits
Standardized benefits – “Essential Health Benefits” including maternity, drug RXs, home-based service, child
ACA effects mortality:
Strong evidence on health insurance and mortality: IRS goldman study
Insurance gained via nongroup private coverage (i.e. Marketplaces)
Led to increased rates of office visits and prescriptions filled
Increased diagnoses of high BP & cholesterol
how many people on medicare?
63 million
medicare part A
hospital care/INSURANCE and tied to payroll tax (traditional)
0$ premium
no out of pocket cap
Medicare part b
outpatient care and doctor services - if you do not have to have part b and usually it is because the person is still working.
no out of pocket cap
20% coinsurance after deducitble
medicare part c
- medicare advantage - bundles A, B and through a private provider that follows medicare rules
many plans to choose from - has an out-of-pocket cap
there are Medicare advantage part d plans
medicare part D
optional prescriptions drug plan
“Donut Hole” was a portion of drug spending without any
coverage, that was eliminated by the ACA
Medicare problems:
Medicare Cost sharing is high: and medicare individuals have limited assets
- Can purchase medigap for cost sharing - but very expensive and tight window to enroll
- You lock into traditional or medicare advantage - both have problems
- Lots of choice in MA- which is a hurdle
- Most physicians take traditional medicare; Medicare advantage can have issues with that
- No long term care
- No dental hearing vision
medigap
- Can purchase medigap for cost sharing - but very expensive and tight window to enroll
- 33% on traditional medicare have medigap
Inflation reduction act
- Emerged from the failed efforts to pass the Build Back Better Act in 2022
- Included several key drug provisions
- including drug price negotiations
