Module 7 lecture, part 5 Flashcards
CHIP is under what legislation?
Title XXI of SSA
Aspects of CHIP
Federal block grants to states to expand Medicaid eligibility
First enroll in Medicaid if qualify
No federal income threshold, but typically for children (up to age 19) in families with incomes up to 200% of federal poverty level
Purpose of CHIP
Cover children whose families’ income exceeded the Medicaid threshold levels
Aspects of HC for the military by US DOD
HC for active duty and retirees, their dependents and survivors
Each branch of the military operates its own medical facilities; svcs are also obtained through civilian providers
TRICARE is the insurance arm
Aspects of the Veterans Health Administration
The largest integrated health svc system in the US
Cost control through global budgets
Svcs organized through 23 geographically distributed Veterans Integrated Service Networks (VISNs)
CHAMPVA covers dependents of disabled veterans
Aspects of the Indian Health Service
Federal program
Comprehensive care to federally recognized American Indian and Alaska Native Tribes and their descendants
IHS programs are the only source of HC for those living on reservations and in rural areas
IHS operates its own hospitals, health centers, and health stations
What are the 2 facets of payment function?
Reimbursement
Disbursement
Reimbursement definition
Determination of methods and amounts of reimbursement in advance of delivery
Disbursement defintion
Actual payment after services have been rendered
Charge definition
A price set by provider
Rate definition
A price set by a 3rd party payer
Fee schedule definition
An index of charges listing individual fees for each type of svc
Who are 3rd party payers?
Insurance companies
MCOs
BlueCross BlueShield
Gov’t
What are the types of reimbursement?
Fee for service
Bundled payments (package pricing)
Resource based relative value scale (RBRVS)
Managed care approaches
Cost-Plus reimbursement
Prospective reimbursement
Aspects of fee for svc
The oldest method
Charges are set by the provider
Each svc billed separately
Later insurers adopted UCR (usual, customary and reasonable) charge
Main drawback is provider-induced demand
Aspects of bundled payments (package pricing)
Reduces provider-induced demand because fees are inclusive of all bundled services
A number of related svcs in one prices
Evidence that prospectively set bundled fees reduced HC spending without compromising quality of care
Bundled Payments for Care Improvement (BPCI) initiative tested in Medicare
Hx of resource-based value scale (RBRVS)
Developed by Medicare to reimburse physicians according to a relative value assigned to each physician service and was eventually adopted by other 3rd party payers
Aspects of relative value units (RVUs)
Established by each CPT coded physician service
Reflect time, skill, and intensity
Separate RVUs assigned for overhead costs and malpractice insurance costs
Adjusted to reflect geographical cost variations
What occurs each yr with RBRVS?
Medicare establishes a dollar conversion factor (CF)
Reimbursement for a svc formula
Reimbursement for a service = RVU x CF
Issue with RBRVS
A type of fee for service: not addressed the issue of volume-driven payment
What are the 3 main approaches of MCOs?
Preferred provider
-Discounted fee for svc
Capitation
Salary combined with productivity-based bonuses in MCOs that employ their own physicians
Aspects of capitation
Per member per month (PMPM) fee to cover all needed svcs
Monthly fee = PMPM rate x number of enrollees
Minimizes provider induced demand and promotes prudence
What is the purpose of cost-plus reimbursement?
To reimburse HC institutions
What is the cost-plus reimbursement?
Per diem rate of per patient day rate (PPD)
What is cost-plus reimbursement based on?
Total operating cost + a portion of capital costs
