Watkins Exam #2 Flashcards
Why have insurance premiums increased so much since 1996?
- Managed Care Backlash
- Decreased competition among providers (aka–Provider Consultation)
Is when Physicians and patients complain about the nature of the restrictions that managed care plans impose
Managed Care Backlash
What do PHYSICIANS argue? /
Physicians argue that they’re losing money because managed cared plans were successful in reducing fees to providers
What do PATIENTS argue?
Patients argue about a confusion between Quantity with Quality (The Chuck-A-Rama Effect)
Mention the main difference between HMO & PPO
HMO’s has a very few providers within their network, and they can negotiate lower rates and premiums to providers
PPO’s- They can’t guarantee the volume, therefore their premiums are higher
What is Provider Consolidation?
Evidence of a wide variety of anticompetitive behaviors within healthcare providers, Price Fixing & Hospital Merges
Is provider Consolidation Always Anticompetitive
No, because the merge of two different hospitals can cause other providers to do the same
Monopoly vs Monopsony
- Monopoly Power is the Large seller, they control price by controlling supply
- Monopsony Power is the Large buyer, they control price by controlling demand
The economic way of quantifying the effect of a change in price on the quantity demanded
Price Elasticity
A statistical process that takes into account the underlying health status and health spending of the enrollees in an insurance plan when looking at their health care outcomes or health care costs
Risk Adjustment
Mention the Medicare’s original risk adjustment model
Adjusted Average Per Capita Cost (AAPCC)
What is the meaning of AAPCC
Adjusted Average Per Capita Cost
Mention the AAPCC Variables
- Age
- Gender
- Institutional Status (nursing home)
- Medicaid Status
- Active Worker Status (employer-sponsored Coverage)
Explain the Measures of Potential Risk Factors Used in the RAND Study
- Demographic Measures aka (age, gender, location, eligible for welfare at baseline)
- Subject Health Status
- Physiologic Health Status
- Prior Utilization
What was the name of the New Medicare’s Risk Adjustment model
Centers for Medicare and Medicaid Services Hierarchical Condition Categories (CMS-HCC)
Mention the characteristics of the New Medicare’s Risk Adjustment model
- Balanced Budge Act (1997) required new model that better incorporated health status.
- Hierarchical Coexisting Conditions
- Renamed: Centers for Medicare and Medicaid Services Hierarchical Condition Categories (CMS-HCC)
Mention the Uses of Risk Adjustment
Adjusting risk across plans in state insurance exchanges
Reduce payment to plans with disproportionately healthy enrollees
Raise payment to those with less-healthy subscribers
How does the ACA impacted Medicare?
It helps lower prescription drug costs for Medicare beneficiaries & helps expand Medicare preventive benefits.
When insured individuals bear a smaller share of their medical care costs, they are likely to consume more care
Moral Hazard
Mention the factors about the RAND Health Insurance Experiment (HIE)
- Robust methodology
- Consistent model applied across many health services
- Results continue to be confirmed by smaller-scale, more narrowly focused studies
Mention the modern pharmacy benefits programs co-payments
Generics
Preferred brands
Non-preferred brands
Biotech drugs
Is the clinical restriction on utilization designed to approve or disapprove care based on clinical necessity.
Utilization Management
Does Utilization Management prevents patients from obtaining services?
NO! It simply dictates that the insurer is not liable for the cost of the service if UM procedures are not followed.
Mention all the UM Techniques
Preadmission Certification Concurrent Review Retrospective Review Denial of Payment Mandatory Second Surgical Opinion Case Management Discharge Planning Gatekeeper Disease Management Intensive Case Management
What is Pre-admission certification?
Refers to approval by a case manager or insurance company representative (usually a nurse) for a person to be admitted to a hospital or in-patient facility, granted prior to the admission
Mention the Home health types of care and qualifications:
- Skilled Nursing
- Physical Therapy
- Occupational Therapy
- Speech therapy
What are the benefits of Home Health?
- Some facilities have “United Way” which is a Non-profit program
Medicaid is for?
low income people, pregnant women, children, the elderly, and those disabilities
What is FMAP?
Federal Medical Assistance Percentage
Is the funding based on expansion., states Federal government matches state Medicaid spending based of the ratio of state to federal per capita income
Describe the state share formula (FMAP)
State share = (state income)2 / (federal income)2 x.45
What does it mean someone is Categorically Needy?
When an individual falls on the following categories:
- Low income
- Blind
- in LTC
- SSI recipient
What does it mean to be Medically Needy?
- When someone Incomes is adjusted for medical spending
What does it mean to be in Special Groups?
Also known as “ Dual eligible”, is when Medicare pays Parts B & D premiums and cost sharing
Which Medicaid Enrollees have the higher enrollment?
Children and Adults, however the Disabled & the elderly have the highest expenditures
What is a RCO?
Regional care organizations
What is CHIP?
(Children’s Health Insurance Plan)
Medicaid program for kids created in 1998 on the Balance Budget Act
Federal Matching funds for coverage of lower income children are?
Up to 350% of poverty line
Why is CHIP a separate program in some states
Because is a stigma, for example the state of Washington calls it Apple
How come the state of Utah came up with co-pays?
By the price of cigarettes’
What is “Crowd-Out”?
Is when people whom are enrolled in private coverage jump to Federal coverage (Medicare)
In which public program “Crowd-Out” is most prevalent and why?
“Crowd-out is more prevalent in CHIP, because parents can save more money
Joint Federal-State program (Medicaid) is a needs-based program designed to provide health insurance coverage to what kind of groups?
- Pregnant Woman
- Disabled
- Children
- Elderly
TRUE or FALSE: The Federal government provides the bulk of the funding for Medicaid and strictly dictates the eligibility requirements as well as services that must be covered
FALSE
TRUE or FALSE : Elderly and disabled individuals comprise the majority of the enrolled Medicaid population and are responsible for the majority of Medicaid expenditures.
FALSE
