Prof quiz 3 hints, part 3 Flashcards
What fraction of total hospital costs is between ages 45 and 84?
2/3
What are the two main cost drivers in hospitals?
Intensity of svcs (cost per day)
Pop growth
What contributed to the hospital downsizing from the mid-1980s onward?
Changes in reimbursement
Impact of managed care
Hospital closures
How did changes in reimbursement contribute to hospital downsizing in the mid-1980s onward?
From cost-plus to prospective payment system (PPS)
Decrease in inpt utilization
How did managed care impact hospital downsizing from the mid-1980s onward?
Emphasis on cost containment
Efficient utilization of resources (care in alternative settings)
Describe hospital closures that occurred in the mid-1980s onward?
Economic constraints
Many rural and urban hospitals had to close
Other hospitals closed wings or used them for alternative purposes
What is ALOS an indicator of?
Severity of illness and resource use
Types of public access hospitals
Community
Non-community
What percentage of the hospitals in 2014 were private non-profit or voluntary?
Over 50%
Types of choice restriction in MCOs
Closed panel
Open access
Definition of closed panel
In-network access
No access outside the panel
What does utilization review ensure?
Appropriate levels of svcs are delivered
Care is cost-efficient
Subsequent care is planned
What are the three main types of utilization review by the time when the review is undertaken?
Prospective UR
Concurrent UR and d/c planning
Retrospective UR
Aspects of practice profiling
Evaluate provider-specific practice patterns
Profile monitoring
Compare to a norm
Feedback to change behavior
Goal: improve quality and efficiency
Somewhat controversial
Aspects of HMOs
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
Aspects of PPOs
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
Aspects of POS
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
Managed care’s effect on quality
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
Backlash, regulation, and aftermath on quality in managed care
Backlash from consumers, physicians and legislators led to regulations against managed care
Relaxed utilization controls
More bargaining power to providers
Organizational integration
Case management and MCOs
Coordination of care for complex and potentially costly cases
A variety of svcs from multiple providers over an extended period
Coordination of an individual’s total HC in consultation with primary and secondary care providers by an experienced HC professional, such as an NP
Service strategies in managed care
Horizonal integration
Vertical integration
Horizontal integration
Extends core product or svc
To control the geographic distribution of a certain type of HC svc
Not for diversification
What does Medigap cover?
The high out of pocket costs in the original Medicare program
To whom is Medigap not available to? What does it not cover?
Those covered by Medicaid or Medicare advantage
Long-term care
