Lead exam 2 Flashcards
- Fee for service
- Per diem
- Episode of illness
- Payment per capitation
a. The unit of payment is the visit or procedure
* Incentive to provide more services to bring in greater revenue.
b: Hospital paid for all services delivered to a patient during 1 day
c: One payment is made for each patient per month or year
-Payment for all services delivered to all patients in a certain time period
- Includes global budget payment of hospitals and salaried payment of MD
d. The physician or hospital is paid one lump sum for all services delivered during one episode illness (DRG’s for hospitals)
* Incentive to limit the number of visits
- A
- B
- D
- C
Who is at risk:
Fee for service
the party paying
the bill (insurance company, government
agency, or patient) absorbs all the risk
How may adding OTs into the intensive care unit (ICU) help with cost containment?
More ots in ICU (more salary, decreased lengeth of stay)
○ More outpatient, community service, and home care
○ Inpatient Rehab
■ Decrease LOS important for cost containment
Can reduce readmission rates
■ More complex patients-‐ less complex going right to subacute
○ Repeal of the 20-year therapy cap for Medicare B
What is bundles of services?
Portion of the risk from payer to provider
If the md sees a patient 10 times rather than 5 for the followup after the surgery, the MD doesnt revieve more money
this is an example of?
Bundles of services
Who is at risk for bundles of services
Payer is at risk to pay for surgeries or tx as requested
provider may not need as many followups
What is the major difference between the British health care system and the United States health care system?
British is Two tiered
- health plan > Capitation > PCP
Pts enroll with PCP (gatekeeper) & are required to use PCP for all non-emergency medical
needs
* MD receives a monthly capitation payment for each patient
* PCP makes necessary referrals for specialist - Separate payment
US is three tiered
HMO > Capitation >Independent practice association > Capitation or FFS >PCP
○ PCP can refer to referral services (specialists, diagnostics)
■ The IPA then pays the referral service as Fee for service
■ If there is extra money at the end of the year, the PCP gets a bonus (incentive for decreased referrals and diagnostics)
○ PCP can refer to referral services (specialists, diagnostics)
■ The IPA then pays the referral service as Fee for service
■ If there is extra money at the end of the year, the PCP gets a bonus (incentive for
decreased referrals and diagnostics)
Is this american or british?
American
PCP can refer to referral services (specialists, diagnostics)
* The IPA then pays the referral service as Fee for service
* If there is extra money at the end of year the PCP gets a bonus (incentive for decreased
referrals and diagnostics)
British or american?
British
What methods are used to improve efficiency while containing cost?
○ Improved longevity & quality of life
○ Reduced mortality & morbidity rates
○ Relief of pain and suffering
○ Enhanced ability to function independently
○ Reduction of fear of illness & death
What are the types of managed care plans and what do they cover?
Three types:
Fee for Service w/Utilization Review (UR)
* Power to authorize/deny payment & services
Preferred Provider Organizations (PPO)
* Insurers contract w/limited number of
MDs/Hospitals on a discounted FFS w/UR
Health Maintenance Organizations (HMO)
* pts required to receive care with providers in
HMO
How is OT impacted by cost containment strategies?
Controlling price Inflation
- Prices of meds 50% higher in US than other countries
- Specialist physician incomes increased rapidly
* Eliminating Ineffective & Inappropriate Care
- Controlling Quantity
- Unnecessary care and procedures
* Eliminating Administrative Waste
- Admin costs to insurance, marketing,
bills/claims, utilization review and not
clinical services
* Innovation
- Services provided by MD can be provided by nurse practitioners/PAs
- Procedures done on out-‐patient basis
New drug that are less expensive and
equally efficacious and well tolerated
Refers to differences between groups in health
coverage, access to care, and quality of care
healthcare disparity or health disparity
healthcare disparity
Refers to higher burden of illness, disability, or
mortality among one group over another group
Healthcare disparity or health disparity
health disparity
What are the different types of “Health Determinants”?
-Neighborhood and physical environment
education
food
community and social votext
healthcare system
“Structural determinants and conditions in which people are born, grow, live and age”
Determinants of health
Networks
■ Socio-economic
■ Cultural
■ Environmental
What social determinants
sse, social support, race, employment ,gender
How do factors like gender affect access to healthcare?
- access for women often begins with finding MD who communicates effectively
-50% of women are more likely than men to leavve an md because of dissatisfaction of care due to talking down to them - physicians are less likely to counsel women
How does race and ethnicity affect access to healthcare
- people of color face significant disparities in access and utilization of care
- non asians, hispanics, blacks, american indians, and alaska natives face increased barriers
- blacks , american indians, and alaska natives fare worse , less likely to have primary care, fewer physician visits, higher rates of no prenatal pain, screening tests and report worse health
- asian people are more likely to be uninsured but have lower rates of cervical screenings but higher hep b and liver cancer
Why has private health insurance coverage decreased over the past decades?
skyrocketing cost of health insurance made coverage unaffordable for many businesses and individuals
workforce shift
unstable rates of employment
Wha
what is a workforce shift?
From highly paid, largely unionized full time manufacturing jobs with empoloyer based health insurance to more low wage part tine whose employers are less likely to provide health insurance
What are the barriers to healthcare access
Which health determinants can’t we change?
age, inherited conditions carrying brca1 or 2 gene, family history , ,sex
What are some of the strategies to reduce health disparities?
How does structural racism impact healthcare policies and health outcomes?
Understand the World Health Organization’s (WHO) determinants of health
framework
What are the mental health issues that are most common at an early vs. late age?
Where are mental health services primarily provided? Outpatient vs. inpatient vs. community based, home health
What is the Mental Health Parity Act?
What is Medicaid Section 1115 Behavioral Health Waivers?
What is the most common service(s) provided to individuals on an outpatient
basis with mental health?
What is the biggest payer for mental health care services in the US healthcare
system?
What is the Mental Health Parity Addiction Equity Act (MHPAEA)?
What did ACA add to the Mental Health Parity Addiction Equity Act
(MHPAEA)?
What is the alternative benefit plan (ABP)?
What is long-term care? Name some of the populations who may need long-term
care services
What are the eligibility criteria for Medicaid coverage for long term care services
and support?
What is the difference between Medicaid and Medicare coverage for LTC?
What is the states’ obligation under the U.S. Supreme Court Olmstead decision?
What is the most common reason for nursing home placement?
Which ACA long-term care program provides additional federal payment for
beneficiaries transitioning from institutional care to the community?
Who provides the most informal care in the home?
What are the types of long-term care services that are paid for/not paid for by
Medicare?
Is the demand for long-term care expected to increase or decrease? And why?
Describe the services provided in each of the following LTC settings and identify
the main differences between services provided: Respite care, Assisted living,
Hospice, Adult day services Respite Care Facilities, and nursing homes?
What is the largest payer for LTC services?
Which LTC is most costly for the healthcare system? And why?
What is the charge of the AOTA Congressional Affairs committee?
What is the AOTA Political Action Committee (AOTPAC)? What does it do?
What historical legislation influenced OT practice overall?
What are some of the ways OT students can advocate for the profession?
What is value-based care and why is it important?
What are ICD codes and how are they categorized?
What is the Service Payment Cycle?
What are CPT codes
What is the significance of documentation?
What is the “8 minute” rule and how do you apply it?
The potential to lose money, earn less, or spend more time without additional payment on a reimbursement transaction is known as…
Risk
This reimbursement type is characterized by the party paying the bill (e.g., insurance company, government agency, or patient) being the one who absorbs all the risk.
FFS
This reimbursement type is characterized by a portion of the risk being shared between payer and provider.
Bundle services
Which unit of payment for services is characterized by “payment per visit or procedure” and has the incentive to provide more services to bring greater revenue?
A. Fee for service
B. Per episode of illness
C. Per diem payments to hospitals
D. Capitation
E. Payment per time period
A
Which unit of payment for services is characterized by “one payment made for each patient per month (or year)”?
A. Fee for service
B. Per episode of illness
C. Per diem payments to hospitals
D. Capitation
E. Payment per time period
D
Which unit of payment for services is characterized by “physician is paid one lump sum for all services delivered during an episode of illness” and has the incentive to limit the number of visits?
A. Fee for service
B. Per episode of illness
C. Per diem payments to hospitals
D. Capitation
E. Payment per time period
B
Which unit of payment for services is characterized by “payment per visit/procedure” and has the incentive to provide more services to bring greater revenue for the visit/procedure?
A. Fee for service
B. Per episode of illness
C. Per diem payments to hospitals
D. Capitation
E. Payment per time period
C
Which unit of payment for services is characterized by “facility is paid for all services delivered to a patient in 1 day”?
A. Fee for service
B. Per episode of illness
C. Per diem payments to hospitals
D. Capitation
E. Payment per time period
c
Which unit of payment for services is characterized by “includes a global budget payment of hospitals and salaried payment of physician (lump sum) per ‘X’ period” and has the incentive to provide more services to bring greater revenue?
A. Fee for service
B. Per episode of illness
C. Per diem payments to hospitals
D. Capitation
E. Payment per time period
e
The usual, customary, and reasonable system (UCR) allowed physicians what?
Flexibility in their fees
Roy sees his physician for a recent onset of diabetes. The physician spent 20 minutes on the exam ($92), finger stick blood glucose ($8), urinalysis ($15), and ECG ($70). Because Roy has no insurance, the physician reduced the bill from $185 to $90.
This demonstrates what construct of FFS?
Usual, Customary, and Reasonable system (UCR)
A physician is contracted with Blue Cross to care for its PPO at 70% of his normal fee. Rick, a PPO patient, comes in with a severe headache and weakness in his right arm. The Physician sees him for 20 minutes at a fee of $100. The Physician gets paid $70 from PPO.
This demonstrates what construct of FFS?
Resource-Based Relative-Value Scale (RBRVS)
Dr. Brett removes Larry’s gallbladder and is paid $1300 by Blue Cross. Besides performing the surgery, he sees Larry three times in the hospital and twice in his office for post-operative visits. He cannot bill separately for visits, so $1300 covers everything.
What unit of payment is described here?
A. Fee for service
B. Per episode of illness
C. Per diem payments to hospitals
D. Capitation
E. Payment per time period
b
Carve-outs and Risk Adjusted are two types of which unit of payment?
A. Fee for service
B. Per episode of illness
C. Per diem payments to hospitals
D. Capitation
E. Payment per time period
d
True or false: A carve-out is typically paid on a FFS basis for services not covered by capitation.
t
Which is more common in the United States, a Two-Tiered Capital system, or Three-Tiered?
3
What are the three tiers of the US capitation system?
PCP gets a capitation or FFS for services, and can refer for specialty services
IPA (independent practice association) pays for referral service for specialty services
Extra money at the end of the year comes as a bonus to PCP (incentive for decreased referrals and diagnostics)
Mr. Lee goes to the hospital for a bleeding ulcer. At the end of a 4-day stay, the hospital sent a $14,000 seven-page itemized bill to the insurance company for payment.
What unit of hospital payment is described here?
A. Payment per diem
B. Payment per procedure
C. Payment per episode
D. Payment per patient
b
Upscale hospital is paid a fixed payment for all hospital services for 1 year.
What unit of hospital payment is described here?
A. Payment per diem
B. Payment per procedure
C. Payment per episode
D. Payment per patient
E. Payment per institution
e
Jane is enrolled in Blue Cross HMO, which contracts with Upscale Hospital to care for Jane’s hospitalization. Upscale receives $60 a month as a capitation fee from the HMO. Jane is healthy and during the 36 months she is an HMO member, the hospital receives $2160 even though she has never been to the hospital.
What unit of hospital payment is described here?
A. Payment per diem
B. Payment per procedure
C. Payment per episode
D. Payment per patient
E. Payment per institution
D
Upscale hospital is paid a fixed payment for all hospital services for 1 year.
What unit of hospital payment is described here?
A. Payment per diem
B. Payment per procedure
C. Payment per episode
D. Payment per patient
E. Payment per institution
E
Fee for service with utilization review (UR), preferred provider organizations (PPO), and health maintenance organization (HMO) are all examples of what kind of healthcare plan?
Managed care plan
Q
Which of the following is not a value-based payment plan?
A. Pay per episode
B. Pay per performance
C. Bundled payments
D. Care coordination payments
E. Accountable care organizations
a
This value-based payment plan is characterized by “pay by how well physicians and providers deliver services”.
A. Pay per performance
B. Bundled payments
C. Care coordination payments
D. Accountable care organizations
a
This value-based payment plan is characterized by “a small capitation payment to the main FFS payment to provide resources and incentives for better management of patients with chronic conditions”.
A. Pay per performance
B. Bundled payments
C. Care coordination payments
D. Accountable care organizations
c
Which Value based payment is this?
Pay for how well physicians and providers deliver services. Supplement basic modes of payment with bonus payments to physicians and hospitals that achieve a specified high level of performance
pay for performance
What valued based payment is this ?
Bundling payment using episode based, physician-hospital based structures into a single payment. Elimination of unnecessary costs
Bundled payments
What valued based payment is this?
PCPs are paid through a blended model that adds a small capitation payment to the main fee-for service payment to provide resources and incentives for better management of patients with chronic conditions.
Care coordination payments
What value based payment is this?
ACO payment models try to make fee-for-service payments to physicians and per diem or episode payments to hospitals function more like a globally budgeted payment model.
accountable care organization
Cost Containment Strategies& Techniques
- Concept of Better Health
- Improved longevity & quality of life
- Reduced mortality & morbidity rates
- Relief of pain and suffering
- Enhanced ability to function
independently - Reduction of fear of illness & death
This value-based payment plan is characterized by “FFS payments made to physicians and per diem or episode payments to hospitals to help them function more like a globally budgeted payment”.
A. Pay per performance
B. Bundled payments
C. Care coordination payments
D. Accountable care organizations
d
This value-based payment plan is characterized by “Uses episode-based, physician-hospital-based structures into a single payment”.
A. Pay per performance
B. Bundled payments
C. Care coordination payments
D. Accountable care organizations
b
True or false: The United States has the highest spending in healthcare and the lowest mortality rate.
t
True or false: Individuals older than 35 years old spend the most money on healthcare.
f OVER 55
Controlling price inflation, eliminating ineffective care, prevention, and innovation are examples of what strategy?
Cost containment
What are the two mechanisms for controlling costs?
Financing: controlling the flow of dollars (premium and taxes) from purchasers to insurers
Reimbursement: controlling the flow of dollars from insurance plans to providers
Regulatory strategies and competitive strategies are two strategies for which mechanism of cost control?
A. Financing
B. Reimbursement
a
Surveillance of and intervention in the clinical activities of physicians for the purpose of controlling costs
utilization management
Controls the number of physicians and other care givers
* Controls the number of hospital beds and technologies
supply limits
Price controls and utilization control, and supply limits are three examples of which mechanism of cost control?
A. Financing
B. Reimbursement
b
How may adding OTs into the intensive care unit help with cost containment?
Less hospital readmission
What is the major difference between the British healthcare system and the US healthcare system?
In the UK basically everything is covered except some prescription costs which sometimes need to be paid out of pocket.
In the US you must pay attention to and understand very clearly the health plan you select
What are the 3 managed care plans and give a brief description?
- Fee-for-service with utilization review:
- Preferred Provider Organizations (PPO):
3.Health Maintenance Organizations (HMO):
Match
1. Insurers contract with limited numbers of MD/ hospital on a discounted FFS with UR
PPO plans= higher costs for SVS for OON
2. A third party payer assume power to authorize /deny payment and services
3. patients are required to receive care with HMO providers
a. Fee for service
b.HMO
c.PPO
- PPO
2.FFS
3.HMO
How is OT impacted by cost containment strategies?
if more cost containments are implemented, then the more ots are in ICU
More out patient community service and home care
inpatient rehab
Could be good — increase in jobs, salary, more complex patients
Or bad — if 20-year cap of Medicare B not repealed
John complains of having a cough, green
sputum, and fever for 1 week. Physician orders a sputum smear, chest x-‐ray, and makes diagnosis of pneumonia. He treats John as an outpatient once a week for 3 weeks and is paid one fee for
everything.
Per episode of illness
PhysicianPayment - Per Time: Salary
Risk? to who?
Payment for all service delivered within a defined period of time into a lump sum
* No risk to physician; however, more work and no additional pay
* Risk to HMO and physician group if expenses too high
