Unit II Flashcards
Why are physicians less likely to accept Medicaid patients than Medicare patients?
Lower reimbursement rates for the same services (~34% less)
Lawrence P. Casalino, MD, PhD
NEJM on why physicians should care for a reasonable number (5%) of Medicaid patients:
core professional principle that physicians should put patient’s interest first
-refusing to care for vulnerable, socioeconomically disadvantage = incompatible with principle
NFIB vs. Sibelius
Court ruling that required Medicaid expansion in all 50 states was unconstitutional, effectively making expansion optional
- only 31 states plus DC have expanded so far
- individual mandates (and penalties) constitutional under General Tax clause
What type of plan do most people in the US have?
Private, employment-based
What type of government plan do most people in the US have?
Medicaid
Where does a majority of the nations $3.0 trillion in health come from?
Health insurance
1) Private health insurance
2) Medicare
3) Medicaid
4) Out of pocket
Who are the big five?
1) United Healthcare
2) Anthem
3) Aetna
4) Humana
5) Cigna
What is Insurance?
An approach to managing risk and uncertainty
- pay a small amount in advance to protect against larger amount later
Who is the financial risk of those who are insured distributed amongst?
The insured population
What are insurance companies in the business of?
1) Accepting risk for a price
2) Setting rates based on magnitude of risk among individuals and communities they insure
What is the basic business model of health insurance?
Insurance companies:
1) collect premiums from beneficiaries
2) pay claims from premiums
3) after admin costs, rest is profit
What can insurance companies determine or work to influence (4)?
1) Size of premiums
2) cost-sharing: how much claims they pay for directly (cost-sharing)
3) negotiations/discounts: which providers they accept claims from and how much they pay/reimburse them
4) kinds of claims that are reimbursable/covered
What two types of ratings are used to shape premiums?
1) Experience rating
2) Community rating
Experience rating
Use how much an individual or group spent on care in the past to determine individual or group premium
Community rating
Use geography, family composition (sometimes age, gender) to set premiums
Why are premiums set based on risk ratings?
likelihood of magnitude, types, and costs of care not uniform across population
When/how did health insurance begin in the US?
1929: provided a hospital insurance plan for public school teachers in Dallas at Baylor university
- 1200 teachers enrolled, $.50/month/21 days of hospital care
What is Blue Cross’ insurance model?
1) Fixed monthly fee from enrollees
2) Hospitals agree to provide care (prepaid plan)
What is Blue Cross’ model based on?
Hospital care
-Began in 1933, endorsed by American Hospital Association, as nonprofit
What is Blue Shield’s model based on?
Physician Services
- 1939
- endorsed by: AMA
What is the significance of Blue Cross and Blue Shield on the national health insurance efforts?
Physicians maintained control = deterrent
Key Moment in Private Health insurance: 1942
Wage freezes imposed during WWII, employers could offer benefits (i.e. health insurance) in place of wage increases
2016 consequence of 1942 wage freezes
Job lock: individual market out-of-reach for many without employer-based insurance options
Key Moment in Private
Health Insurance: 1954
IRS rules that employment-based health coverage not subject to taxes
2015 consequence of IRS exemption of employment-based health coverage
- ~$250 billion tax subsidy (favoring the wealthy)
- over purchase of insurance
- overconsumption of health care
How were premiums calculated for most of the history of private health insurance in US (until late 1980s)?
Fee-for-service (indemnity) plans
Why did managed care become popular in the 1970s to early 1980’s?
Costs were soaring and there were no mechanisms to control it
Managed care
Organized approach to delivering a comprehensive array of health care services to a group of enrolled members through efficient management of services needed by the members and negotiation of prices or payment arrangements with providers.
What are the primary strategies of cost-control for managed care programs (6)?
1) Choice restrictions
2) Gatekeeping
3) Case management
4) Disease management
5) Pharmaceutical management
6) Utilization review
What are examples of choice restrictions as an approach to controlling costs?
employed/salaried physicians, care networks
Gatekeeping
Cost-control mechanism by which a single provider is responsible for providing referrals to a patient before a patient can access other sources of care
Case management
Separate health care provider coordinates care for patients with complex and costly conditions
Disease management
special outreach for beneficiaries with chronic conditions
What are examples of pharmaceutical management as a mechanism to control costs?
formularies, tiered cost-sharing
What are the types of utilization review?
Prospective, concurrent, retrospective
What are three reasons why the cost of health care rises?
1) Growth in technology
2) Aging poplin
3) Increasing public expectations
What has been the trend in private health insurance?
Managed care has become increasingly popular, while FFS has decreased dramatically
What is Kaiser’s health plan model?
Prepaid group plan; capitation model
Why did Kaiser hire its own staff and build it own facilities?
AMA opposition
HMO (4)
1) Tight coordination and control of health care services; PCP = gatekeeper
2) Very narrow network of providers (no out-of-coverage for patients)
3) Salaried providers; capitated rate per patient negotiated with employers
4) Generally lowest costs to patients amongst managed care options
HMO Act of 1973
Federal law that encouraged the establishment and growth of HMOs by providing federal subsidies, quality standards, and required HMO option to be available to employees
What happened to HMOs in the 1980s/1990s (3) ?
1) Massive growth
2) Move to for-profit
3) new models for provider relationships
Why was there backlash in the 1990s over HMOs?
Patient concerns over quality of care, access to providers, utilization controls
Around what years did the percent of covered employees enrolled in HMOs peak?
1996-2000
What is Yale Health an example of?
Staff model HMO
What is a Staff model HMO?
Physicians are salaried employees of HMO who only see HMO patients; PCP = gatekeeper to specialist
What is a PPO (4) ?
1) Insurer contracts with groups of physicians and hospitals; receives discounts for care provided “in-network”
2) Patients can receive care outside of network (usu higher cost sharing = deterrent)
3) PCP gatekeeping = less common
4) Cost more than HMOs to enrollees; insurers have less ability to control costs
What is a POS Plan?
A hybrid of HMO and PPO
- like HMO: tight provider network, capitation, gatekeeper
- like PPO: some out of network services available; higher cost caring; some gatekeeping
What is the current ranking of popularity of the types of managed care plans?
1) PPO
2) HMO
3) POS
What are the main distinguishing factors amongst the main types of managed care plans?
1) choice of provider
2) delivery of services
3) payment and risk sharing
HMO
choice of provider, delivery of services, payment and risk sharing
1) In-network only w/ salaried/contracted staff
2) Gatekeeping
3)
- Payment: Providers mostly paid capitation, some FFS
- Risk sharing: with providers under capitation
PPO
choice of provider, delivery of services, payment and risk sharing
1) In-network and out-of-network, contracted providers only
2) No Gatekeeping
3)
- Payment: discounted fee schedules
- Risk sharing: none
POS
choice of provider, delivery of services, payment and risk sharing
1) In-network + out-of-network, contracted providers only
2) Limited/no gatekeeping
3)
- Payment: capitation + FFS
- Risk sharing: some
What is the high-deductible health plan also called?
Consumer Directed Health Plans
High-Deductible health plan
High deductible and coinsurance, often used in conjunction with HSAs (with tax advantages)
For high-deductible health plans, who has more financial risk compared to other Managed care options?
The enrollees
What do supporters of HDHPs purport is a benefit of this type of managed care?
“Skin in the game” = promotes greater personal responsibility over health care expenditures
What do critics of HDHPs purport is a negative of this type of managed care?
Wealthier, healthier people more likely to choose this option = rest of insurance pool poorer, sicker (–> higher premiums over time)
Of those enrolled in Medicare Advantage, what is the ranking of managed care plans?
1) HMO
2) Local PPO
3) Regional PPO
What are the three main problems with private health insurance in the managed -care era at the time the ACA was passed?
1) For insured: managed care plans deny necessary care, provide lower care, wide variety in cost of insurance + types of coverage
2) For those w/o employment-based insurance: private insurance unaffordable
3) Widespread provider dissatisfaction with how managed-care reqs affect ability to deliver kind of care they would like.
What are the three main activities of the Department of Veterans Affairs?
1) Healthcare
2) Benefits (GI Bill - Education, Pensions/Compensations)
3) Cemeteries
What is the VA model?
VA healthcare owns and operates health care facilities (inpatient & outpatient), employs clinical and administrative staff
- largest healthcare delivery system in the country
What type of integration is the VA system and example of?
Vertical
How is VA healthcare different from Medicare and Medicaid?
It is not an entitlement program; meeting eligibility criteria alone doesn’t guarantee benefits
How is the budget for VA Healthcare determined?
annual Congressional budget appropriations; up to VA to decide how to allocate money each year amongst three main functions
What are priority groups (VA healthcare)?
8 priority groups used to organize which groups of veterans are enrolled before others
Who is typically in the highest tier of priority groups for VA healthcare and what is the ranking based on?
Those with significant service-related disabilities.
Disabilities are based on “Disability Ratings Schedules”
Who is typically in the middle tier of priority groups for VA healthcare and what is the ranking based on?
Medicaid-eligible, low-income veterans
Who is typically in the lowest tier of priority groups for VA healthcare and what is the ranking based on?
Incomes above thresholds
OR
Minimal/no service-related disability
Note: copays for this group
What is the general consensus for cost sharing for VA healthcare?
1) None for most vets, service-connected injures (highest tier), below income thresholds
2) Lowest priority required to pay co-pay
What is the quality of VA healthcare?
Favorable compared with care in non-VA facilities; high patient satisfaction
Why are there access issues in the VA system?
Eligibility/priority policies given budget constraints
What is the access like for vets with VA healthcare benefits?
Long waits for outpatient appointments; difficulty scheduling within ‘desired date’ target of patient/provider
VA Choice Program
veterans can receive care outside of the VA if:
1) Wait time for appt exceeds 30 days beyond desired date
OR
2) Veteran lives more than 40 miles from nearest VA
- Approved by Congress (2014)
- implementation slow
- long-term future uncertain
- Congress looking for more privatization
VA Secretary Robert McDonald - May 2016
Appointment days not important; veteran satisfaction is better measure.
Compares waiting in line at Disney to waiting to see doctor
What are the three main options to address the uncertain future of the VA Health Care System?
1) Increase funding to expand current system
2) New approaches to redirect more/all VA funding to private healthcare providers/facilities
3) Refocusing VA facilities and personnel to subset services more closely related to service-related conditions
Tricare
- DoD Defense Health Agency for seven uniformed services
- ~9.5 million beneficiaries
- Entitlement program: $52 billion annual spending (10% DoD budget)
Who handles the day-to-day management of Tricare?
Government contractors (large private health insurers)
What does Tricare resemble?
Medicare Part C/ Private insurance program
Who is the main private insurer for Tricare?
Was United Healthcare; now Humana and Centene Corp
Tricare for Life
Medigap-style plan for eligible retired veterans who are also Medicare eligible
Given criticisms that the “Federal health system [is] currently a fragmented patchwork,” what are the (5) opportunities for coordination?
1) Transportation
2) Duplicate payments
3) Facilities
4) IT systems
5) Value-based purchasing
Who owns the Indian Health Service?
Dept of Health and Human Services
How many people have access to Indian Health Service benefits?
~1.5 million out of ~2.2 million AIAN
How does Indian Health Service operate?
- 49 hospitals
- 364 health centers
- contracts with private providers in underserved/difficult to access areas
What is the annual budget of Indian Health Service?
~$4.6 billion
- not an entitlement program; payer of last resort
- CHRONICALLY UNDERFUNDED
Why was Indian Health Service created?
Established in 1802 and formally agreed to in 1832 as partial compensation for land seizures
Snyder Act (1921)
Funds “for relief of distress and conservation of health…[and] fro the employment of physicians…for Indian tribes throughout US”
Indian Self-Determination and Education Assistance Act of 1975
Tribal authorities can assume responsibility for providing health services (IHS grants/contracts)
Indian Healthcare Improvement Act
Permanent as part of ACA (2010)
1931/ Herbert Hoover: Argument in Favor of Health Care Reform
Modern medicine can be brought within reach of persons of average means
- Committee on the Cost of Medical Care
1931/ Herbert Hoover: Argument Opposed to Health Care Reform
Medical soviets…such plans will mean the destruction of private practice.
- American Medical Association
1934-38/ Franklin Roosevelt: Argument in Favor of Health Care Reform
A comprehensive program designed to increase and improve medical service for the entire poplin
- Committee to Coordinate Health and Welfare Activities
1934-38/ FDR: Argument Opposed to Health Care Reform
Opposition to all forms of state medicine.
-AMA
If we have socialized medicine in America…standards of medical practice will degenerate…and patients will suffer.
-NMA
1948/Harry Truman: Argument in Favor of Health Care Reform
A system of Government prepayment health insurance to provide universal access to hospital and physician care.
-Ewing Report
1965/ LBJ: Argument in Favor of Health Care Reform
To improve health care for the American people, [I propose] hospital insurance for the aged under social security.
-President Johnson
1993/ Bill Clinton: Argument in Favor of Health Care Reform
We must make this our most urgent priority: giving every American health security, health care that can never be taken away.
-President Clinton
2010/ Barack Obama: Argument in Favor of Health Care Reform
We have now just enshrined the core principle that everybody should have some basic security when it comes to their health care.
-President Obama
1948/ Harry Truman: Argument Opposed to Health Care Reform
Nations that embark on such programs move inevitably onto a socialized state in which…practically all public services become nationalized.
-AMA
1965/ Lyndon Johnson: Argument Opposed to Health Care Reform
The President’s proposal would be the first step toward establishment of socialized medicine in the US
-AMA
1993/ Bill Clinton: Argument Opposed to Health Care Reform
New government bureaucracies will cap how much the country can spend on all health care
-“Harry and Louise” TV Ads, sponsored by the the Health Insurance Association of America