MC Chpt 2 Types Of Insurers, MCOs, IDSs

Question 1

Types of health insurers and MCOs

Part 2

Answer 1

1. EPOs- exclusive provider organizations
   
   1. 1 cover only services provided by participating providers Exocet emergencies
   2. 2 do not require a member to go through a PCP gatekeeper
   3. 3 use an existing PPO network for in-network services
2. POS - point of service plan
   
   2. 1 combine HMO with indemnity for care outside of HMO
   3. 2 indemnity coverage incorporates high cost sharing
3. Consumer-Directed Health Plans (CDHP)
4. Third party administrators (TPAs)
5. Consumer operated and oriented plans (CO-OP)
   
   5. 1 COOPs offer coverage through state exchanges
   6. 2 cannot be run by government
   7. 3 can’t have been an insurer on July 16, 2009
   8. 4 licensed by state and complies with all state laws
   9. 5 must be governed by a board

Question 2

Types of health insurers and MCOs

Part 3

Answer 2

1. Health Maintenance Organization
   
   1. 1 responsible for financial aspects and a delivery system
   2. 2 members see PCP for services and to access specialty care
   3. 3 things that differentiate HMOs from health insurers:
      
      1. 3.1 licensed by states under different laws than insurers
      2. 3.2 must provide adequate assess to providers
      3. 3.3 must include no balance billing clauses
      4. 3.4 must allow direct assess to PCPs and ob/gyn
      5. 3.5 must have written policies for physician credentialing, UM, QM
2. 4 open panel (IPA and direct contract)
   
   1. 4.1 contract with private physicians to provide care
   2. 4.2 open to private physicians who meet HMOs terms
3. 5 Closed panel (group model and staff model)
   
   1. 5.1 provide care through medical group associated with HMO or physicians employed by the HMO
   2. 5.2 considered closed to private physician

Question 3

HMOs: open panel bs closed panel HMO

Answer 3

1. Advantages of open-panel HMOs
   
   1. 1 more easily marketed b/c large panel by physicians
   2. 2 easier for members to find physicians conveniently located
   3. 3 medical management may be delegated in IPA model
   4. 4 They are less costly to set up and maintain
2. Disadvantages of open panel HMOs
   
   2. 1 HMO has little ability to manage the care
   3. 2 premium are often higher than those of closed panels
3. Advantages of closed panel HMOs
   
   3. 1 ability to manage the medical care
   4. 2 Delegation of medical management to the group
   5. 3 convenience as buildings house doctors, X-Ray, pharmacy
4. Disadvantages of closed-panel HMOs
   
   4. 1 people already have a doctor and do not want to change
   5. 2 locations of offices may not be convenient
   6. 3 only feasible where the market is large
   7. 4 they are most costly to set up and maintain

Question 4

Type of HMOs

Answer 4

1. Independent practice assiciation (IPA)
   
   1. 1 HMO contracts with an association of physicians, the IPA
   2. 2 IPA physicians maintain their own offices
   3. 3 HMOs pay IPA capitation for all phys services
2. Direct contract model
   
   2. 1 HMOs contract directly with independent physicians or medical groups
   3. 2 HMO does the credentialing, UM, etc
   4. 3 HMOs pay physicians through capitation and FFS
3. Group model
   
   3. 1 HMO contracts with a multi-specialty group. Physicians are employed by the group
4. Staff model
   
   4. 1 the physicians are employed by the HMO. Physicians are paid on a salary basis
5. True network model
   
   5. 1 HMO contracts with more than one medical group or physician organization
6. Mixed model HMOs
7. Open accessed HMOs
   
   7. 1 like POS, member selected PCP and gets highest benefits using HMO system, but may access specialty care directly with less coverage
   8. 2 like EPO only services in network are covered

Question 5

Integrated Health Care Delivery System (IDS)
Definition and types
Part 1

Answer 5

1. Definition: providers coming together to manage health care and contract with HMOs, PPOs, insurance companies
2. Independent Practice Association (discussed earlier)
3. Physician practice management companies (PPMCs)
   
   3. 1 publicly traded companies need to report positive earnings
   4. 2 most failed bc lacked incentive for phys to be productive
4. Group practice without walls (GPWW)
   
   4. 1 physicians aggregate practices into a single legal entity, but practice in their independent locations
   5. 2 physicians personal income affected by the performance of the group

Question 6

Integrated Health Care Delivery System (IDS)
Definition and types
Part 2

Answer 6

1. Physician-hospital organization (PHO)
   
   1. 1 allows a hospital and its physicians to negotiate with payers
   2. 2 if do not accept financial risk, difficult to operate within federal antitrust regulations
2. Management services organizations (MSO)
   
   2. 1 physician remains independent private practitioners
   3. 2 MSO provides support services to member physicians
   4. 3 MSO receives compensation from physicians at fair market value
3. Foundation model
   
   3. 1 foundation purchases the physician practices, physicians become members of a medical group
   4. 2 foundation is only source of revenue to the medical group
4. Provider-sponsored organization (PSO)
   
   4. 1 contract directly with Medicare on an at-risk basis, bypassing existing Medicare HMOs
   5. 2 deep financial losses
5. Hospitals with Employed Physicians
   
   5. 1 Advantages: increases the hospital negotiating leverage, professional management, better electronic transactional systems, coordinate care, more stable physician base

Question 7

Organizations emerging under health reform

Answer 7

1. Accountable care organization (ACOs)
   
   1. 1 the following are eligible to form an ACO:
   2. 1.1 ACO professionals in group practice arrangement
   3. 1.2 Networks of individual practice arrangements
   4. 1.3 partnerships between hospitals and ACO professionals
   5. 1.4 Hospitals employing ACO professionals
   6. 1.5 Rural health clinics
   7. 1.6 federal qualified health centers
   8. 1.7 critical access hospitals
   9. 2 ACO must be formed for the purposes of:
   10. 2.1 receiving and distributing shared savings, repaying shared losses to CMS, ensuring quality compliance
2. Patient-centered medical home (PCMH)
   
   2. 1 Patients have ongoing relationships with a personal physician
   3. 2 Patients received care from a team, led by personal physicians
   4. 3 Patients care is coordinated across the health care continuum
   5. 4 evidence-based medicine, continuous quality improvement, patient engagement
   6. 5 enhanced assess to care
   7. 6 payment to PCMHs recognize reduced hospitalization and quality improvement
   8. 7 a plan participating in a state exchange may provide coverage through a PCMH

Question 8

Types of health insurers and MCOs

Part 1

Answer 8

1. Indemnity insurance
   
   1. 1 indemnified beneficiary from financial cost of health care
   2. 2 few controls to manage cost
   3. 3 providers balanced billed
2. Service Plans
   
   2. 1 the plan contracts directly with providers
   3. 2 no balance billings
3. Managed indemnity
   
   3. 1 MC overlays provide some cost control
   4. 2 retain freedom of choice of provider
   5. 3 covers out-of-plan services
4. Preferred provider organizations (PPOs)
   
   4. 1 Participating providers agree to PPOs payment levels
   5. 2 providers abide by UM requirements
   6. 3 members who see PPO providers have higher coverage
   7. 4 may be operated solely for the benefit of its owner
      
      4. 4.1 or, it may be a rental PPO