Managed Care test 1 Flashcards
Where was the first example of an HMO?
TAcoma, Washington was a prepaid group practice for a set premium in 1910.
What happened in Oklahoma that was part of the history of HMOs?
establishment of rural farmers’ cooperative health plan in Elk City in 1929.
How did the AMA respond to prepaid groups?
takes a strong stance against them in favor of individual payments or indemnity-type insurance
Tell me about the birth of the blues…
Came about during the depression. 1929 Blue Cross comes out of baylor and helps get teachers prepaid care. 1939 - blue shield comes out of physicians in pacific northwest who want to give employees coverage.
How many workers had insurance in 1940?
10%
What happened in 1942 which changed health insurance?
The stabilization act imposed wage and price controls but allowed benefits plan to aovid taxing.
What Act gave the states the power to regulate insurance?
The McCarran-Ferguson Act.
Can you explain the purpose of employee benefits and how they could have been included in the health care benefit package?
Know about stabilization act of 1942 and how it let benefits not be taxed.
By 1955 how many workers had coverage?
70%
What was JFK trying to do before his assassination?
trying to make national health plan for all Americans, especially elderly and poor.
What happened in 1965 which was so important?
Creation of medicare and medicaid which was opposed by organization medicine.
When were PPOs created?
in the 1970s, Samuel Jenkins startedd to negotiate discounts with hospitals and later on with physicians.
What happened in 1973 and 1974 which affected managed care?
passage of federal HMO ACT and Employee Retirement Income Security Act (ERISA)
Tell me about the 1973 Federal HMO Act.
Nixon proposed national health insurance. They noticed that medicare costs were out of control. Medicare paid by a cost plus basis (pay cost +2%).
Wanted to do two things?
- moving away from FFS
- provisio nof preventive care.
This act applied only to the commercial sector.
Gave start up funding to new HMOs, HMOs could elect to be federally qualified if meeting certain requirements, required to community rate premiums, employers >25 employees had to offer at least two types of HMOs to their employees.
What are the types of HMOs?
closed panel, group, staff model, open panel, IPA/network model
What were the drawbacks of the 1973 Federal HMO ACT.
HMOs could not compete because of the federal plan requirements, gov was slow in issuing regulations that implemented the act, employers delayed making HMOs available (dual-provision was done in 1995). After dual choice provision gone in 1995, states regulated HMOs.
Tell me about the 1974 Employee Retirement Income Security ACt (ERISA).
This is where we get the origin of self-funding option for employers offering benefits plans (now over 50% of employers is self-funded).
ERISA exempts the benefits plan from most state laws and regulations such as state mandated benefits and state premium tax. Therefore, the state cannot mandate coverage requirements for self-funded plans.
What is an insured, indemnified plan?
legal contract in which insurer accepts risk on behalf of insured in return for a premium
When was CMS created and what was it called?
1977, health care financing administration.
When did we start talking about quality?
national committee for quality assurance
When do HMOs really start to appear?
early 1980s
When did we start to see HMOs in Medicare?
in 1982 when we had the passage of the tax equity and fiscal responsibility act (TEFRA). Ronald Reagan was president. This is also the act where we get DRGs. Also we have the prospective payment system.
What were TEFRA units?
the health care units which remained under cost plus after PPS was imposed on acute care inpatient. This would be a lot of outpatient stuff.
What is COBRA?
consolidated omnibus budget reconciliation act of 1985.
WHAT did COBRA do?
EMTALA. This also had COBRA insurance. Created limitd health insurance coversion rights.
What is OBRA and what does it do?
omnibus budget reconciliation bill. Change medicare FFS payments to resource based relative value scale.
What is the resource based relative value scale and where did it come from?
OBRB.
What year did the rate of change of health care costs hit a bottom?
1996.
What remains of the true HMO?
utilization management, discharge planning. These are cost containment mechanisms.
Why did integrated health care delivery systems form?
as a response to managed care so that providers could have more negotiating power. Also, ability to take on risk for medical costs.
What are the multiple forms of integrated health caredelivry systems?
physician hospital organization, management service organizations, physician practice management company
What are “carve out” companies?
Those who specialize in managing a single aspect of care such as behavioral health care.
What did the balanced budget act of 1997 do?
Reduced payment levels to Medicare +Choice HMOs in most of the country below the rate of increase in medical costs and imposes additional administrative burdens.
What does HIPAA do?
- Increases access to health insurance, mandates some inpatient coverage for certain conditions, mandates mental health parity, does privacy and security.
Why do we have managed care backlash?
employers put a lot of employees in managed care plans, not as much choice, gatekeepers, overzealous utilization management, leads to patient’s bill of rights.
What is a PPO?
preferred provider organization - like HMO but more freedom to go out of network because you don’t have the gatekeeper.
What about the Medicare Modernization Act of 2003?
provided drug benefits to seniors, converted Medicare+Choice program into Medicare Advantage.
What do we mean when we talk about disease management?
focuses on the small percentage of members who have the highest costs
What two criteria do diease management conditions need?
- condition is common
2. condition is likely to respond to a disease management program
What do disease management programs emphasize?
prevention of exacerbations and complications utilizing evidence-based practice guidelines, regularly updated, and patient empowerment strategies, to avoid or reduce admissions
