Section 7/Week 7

Question 1

What was the schedule of acceptable fees for physician services under Medicare originally based on?

Answer 1

UCR (usual, customary, reasonable) allowable fee.

Physicians were overcharging.

Question 2

What system replaced this first one?

Answer 2

The RBRV (resource based relative value) system based on how many resources each service require.

This system is preferred to keep costs down.

Question 3

What is the fundamental problem with the SGR?

Answer 3

• Geographic scale is too big

- Not feasible

Question 4

What are potential solutions for reforming the Medicare physician payment system?

Answer 4

This is tough because Medicare Part A and B are separate.

• smaller regions
• accountable care organizations

Question 5

Why did Medicare start incentivizing patients to join HMOs?

Answer 5

To save $$$

Question 6

How did Medicare incentivize HMOs to treat Medicare patients

Answer 6

• Federal government would pay HMOs that were enrolling Medicare beneficiaries on cost reimbursement
• HMOs expected to save 70%

Question 7

Why did Medicare HMOs experience favorable selection?

Answer 7

They enrolled disproportionatley healthy people and made significant profits.

-Law said that profits had to be given back to the patient in benefit or reduction. Solution was to provide more coverage.

Question 8

What impact did HMO increasing usage have on Medicare’s costs?

Answer 8

Drove costs up again, as more care was being provided unnecessarily.

Question 9

What is Medicare+Choice?

Answer 9

Product of Balanced Budget Act of 1997, allowed for a wider range of managed care options.

Question 10

What was the unintended consequence of decreasing hospital payments under the Balanced Budget Act of 1997?

Answer 10

Hospitals were facing hardships, often times having to close.

Especially true for teaching hospitals and urban hospitals.

Question 11

What was the unintended consequence of risk-adjusted capitation premiums to Managed Care Plans-meaning adjusting the premium annually based on the previous health status of the beneficiary?

Answer 11

Decrease in HMO enrollment because of increased premiums and decreased availability.

Question 12

What was the Medicare Modernization Act of 2003?

Answer 12

• attempt to bring HMOs back after mass exodus
• increased capitation rates
• created Part D
• ended up paying 114% of the costs of Traditional Medicare

Question 13

Medicare HMOs

Answer 13

With rising health care costs in 1970s and 1980s, the federal government allowed beneficiaries to enroll in certain approved HMOs

Question 14

Balanced Budget Act of 1997

Answer 14

An attempt by Congress + President Clinton to change the financing and organization of many federal policies, including Medicare reform

Question 15

Medical Savings Accounts

Answer 15

A high deductible plan in which Medicare gives individuals in Medicare the difference between the average cost to be enrolled in an HMO and the patient’s high deductible. Excess funds are put into a savings account and can be used for health care or other income taxed related spending.

Question 16

Medicare + Choice

Answer 16

An attempt by Congress to allow Medicare enrollees market-based choices for their care. They had a wide range of choices from traditional Medicare to PPO, HMOs, POS, MSAs and other combinations

Question 17

What populations are covered under Medicaid?

Answer 17

Rather than being universally available to all poor people, it covers only certain subgroups

Question 18

How is Medicaid payment structured?

Answer 18

Rather than combining a service plan and an insurance plan, it originally was strictly an insurance plan.

Question 19

How is Medicaid administrated

Answer 19

By the states under broad federal guidelines.

Question 20

Whos eligible for Medicaid?

Answer 20

• Members of low-income families with children
• Elderly people who meet income requirements
• Disabled people

Question 21

What services are provided by Medicaid

Answer 21

There is a basic level of services a state’s program must provide in order to qualify for financing, but if a state so desires they can add any additional services and receive federal matching funds.

Question 22

Many states have constitutions that ban deficit spending. Why is this of particular concern in regards to Medicaid during recessions?

Answer 22

More people are unemployed and go on Medicaid
Revenue for Medicaid is cut because less people are employed, paying taxes
So, states must cut spending in Medicaid or other public services at a time when these services are needed most.

Question 23

What was the original language of the Medicaid amendment in 1965

Answer 23

• Provided federal matching funding to states to cover medical costs for the “poor” who met certain tests
• Sate enrollment was optional, encouraged by federal matching funds
• Based largely on the ‘insurance’ model

Question 24

How has Medicaid been impacted by the recession

Answer 24

-Rose by nearly $6million

Question 25

Why are Medicaid patients abusing emergency rooms?

Answer 25

Because there is a poor availability of doctors is largely responsible for the following relationship.

Question 26

Oregon Health Plan

Answer 26

• Another way of confronting Medicaid costs
• Required a special waiver from the federal goverment
• Led to the explicit rationing of medical care for Oregon’s poor

Question 27

What are changes to Medicaid under the ACA

Answer 27

• All people with income below 138% of the poverty line are automatically eligible for Medicaid, regardless of family status
• Newly enrolled Medicaid beneficiaries will have matched funds from the government at 100% of the cost, gradually reducing to 90%
• State participation is optional

Question 28

How is the physician payment system under Medicaid changed under the ACA

Answer 28

-Beginning in 2013, any primary care physician treating a Medicaid patient will be paid at the same rate as the Medicare rate