Managed care lecture, part 2

Question 1

What are the 3 main types of MCOs?

Answer 1

Health maintenance org (HMO)
Preferred provider org (PPO)
Point-of-service (POS), hybrid of HMO and PPO

Question 2

Aspects of HMOs

Answer 2

Both medical care for illness and preventive care
PCP as gatekeeper
Capitation
In-network access (except hybrid and triple-option plans)
Carve outs for special svcs
Required to comply with standards of quality

Question 3

Aspects of PPOs

Answer 3

Contracts with a grp of physicians and hospitals
Open-panel option
Discounted fee arrangement with providers (no direct risk sharing)
Fewer restrictions to the care seeking behaviors: no gatekeeping and other controls

Question 4

Aspects of POS

Answer 4

HMO features: gatekeeping utilization controls, capitation
PPO feature: open access option available at the point of svc
Later, the need for POS plans became less important

Question 5

What are the models of HMOs?

Answer 5

Staff
Group
Network
Independent practice association (IPA)

Question 6

Staff model

Answer 6

Employ physicians on salary
Contracts for only uncommon specialties and hospital svcs
Greater control over practice patterns of physicians
Least popular model

Question 7

Group model

Answer 7

Contract with a single multispecialty grp practice
Separate hospital contracts
Grp practice is paid a capitation fee

Question 8

Network model

Answer 8

Contract with more than one grp practice
A wider choice of physicians
Diluted utilization control

Question 9

Independent practice association model

Answer 9

An intermediary representing physicians
HMO contracts with IPA
IPA (not HMO) contracts with providers
Less leverage in changing physician behavior
D/t a surplus of specialists in many IPAs, there is some pressure to use their svcs

Question 10

Advantages of staff model

Answer 10

Greater control of practice patterns of physicians
Convenience of one-stop shopping

Question 11

Disadvantages of staff model

Answer 11

Fixed salary expense can be high
Expansion into new markets is difficult
Limited choice of physicians

Question 12

Advantages of group model

Answer 12

No salary or facility expenses
Well known practice may lend prestige

Question 13

Disadvantages of grp model

Answer 13

Difficulty with svc obligations if a contract is lost

Question 14

Advantage of network model

Answer 14

Wider choice of physicians

Question 15

Disadvantage of network model

Answer 15

Dilution of utilization control

Question 16

Advantages of IPA model

Answer 16

Eliminates the need to contract with various providers
Transfers financial risk to the IPA
Choice of providers

Question 17

Disadvantages of IPA model

Answer 17

Difficulty with svc obligations if a contract is lost
Less leverage in changing physician behavior
Dilution of utilization control
A surplus of specialists

Question 18

Trends in employment based health insurance enrollment with managed care

Answer 18

Plans with dollar-level employer contribution lead to workers paying more if they choose a more expensive plan
Enrollment of workers in PPO: 61% in 2005, 57% in 2013
Health insurance exchanges
-Managed care plans to be dominant payers in the exchanges under the ACA
-Must comply with ACA mandates

Question 19

Medicaid enrollment trends with managed care

Answer 19

Enrollment of Medicaid beneficiaries in HMOs increased to 85% in 2015
Primary care case management (PCCM) model used in many states
Requires enrollee to choose PCP
PCP coordinates enrollee’s care and is paid a monthly fee for doing so

Question 20

Medicare enrollment trends in managed care

Answer 20

Level of participation in Medicare part C depends on the amt of reimbursement
In 2015, 32% of Medicare beneficiaries in managed care
Payments to Medicare Advantage plans will be reduced under the ACA

Question 21

What percentage of workers were enrolled in PPOs in 2016?

Answer 21

48%

Question 22

Managed care’s impact on cost?

Answer 22

Better value than indemnity insurance
Backlash from consumers and providers led to weaker cost control efforts
Full potential was not realized

Question 23

Managed care’s effect on access

Answer 23

Good access to primary care and preventive svcs in certain key areas
On a larger scale, impact on access is not well established

Question 24

Managed care’s effect on quality

Answer 24

Overall, quality of care in MCO plans = traditional FFS
No evidence of skimping on care bc of capitation
Lower quality in for-profit plans vs non-profit plans
Enrollees of Medicare Advantage have a higher likelihood of rehopsitalization compared to those in original Medicare

Question 25

Backlash, regulation, and aftermath on quality in managed care

Answer 25

Backlash from consumers, physicians and legislators led to regulations against managed care
Relaxed utilization controls
More bargaining power to providers
Organizational integration