Health Care Models
_______ rewards providers for providing more care to patients.
BONUS: Name the concerns of this system
Fee for service payment (FFS)
BONUS:
Major concern for this system include higher cost and can lead to better OR worse outcomes for patients.
List the eligibility requirements for Medicare.
BONUS: What is the additional requirement for someone to enroll in Medicare Part D?
Older than or 65 years old
OR less than 65 years old:
-Disabled
*Waiting period: need to get disability social security benefits for 24 months before eligible for Medicare
-End stage renal disease (ESRD)
*kidney transplant, dialysis (3 years after transplant = covered)
BONUS: Must also be enrolled in Medicare Part A OR Part B.
______ _____ helps patients pay for health care services at free or reduced cost.
Charity care
What are the lowest cutoffs for Medicaid eligibility for children and pregnant women?
133/138% of the Federal Poverty Level (FDL)
True/false: There is not out-of-pocket max for Medicare Part A and Part B.
True.
Comparing cost sharing for the different parts:
Deductibles: apply to some services in Part A and B
Coinsurance: apply to some services in Part A and B (typical for B is 20%)
Copayment: applies to some services in Part A and B
Why do narrow provider network plans have lower premiums?
BONUS: Define what a provider network is and the challenge of network plans.
Narrow networks have a lower premium due to many factors including:
- Patients negotiate with providers to get lower reimbursement rates
- Plans have fewer high-cost providers within the network
- Premiums are based on enrollees expected health care costs, so patients who choose narrow network plans may be healthier and require less health care (can create adverse selection)
BONUS:
Provider network is a group of providers under a contract with insurance. Challenge is that patients may not know if they are in a broad or narrow network plan (can result in surprise bills from out-of-network facilities, physicians, etc)
List the services not covered by Medicare.
Hearing aids
Eye examinations related to prescribing glasses, eyeglasses/contact lenses
Dental: cleanings, fillings, tooth extractions, dentures
Long-term care
How is charity care funded?
donations, grants, and providers that volunteer
______ administer the Medicaid program but they must do so in accordance with the _______ guidelines.
States; federal
**Note: this is why each state varies for Medicaid eligibility*
What is the definition of balance billing?
Patient is charged the difference between insurance allowed amount and how much the provider charges.
Who is at risk in a capitation payment plan? Who would be at risk in a fee for service payment plan?
Capitation: provider at risk
Why? Payment is pre-determined, so 5 visits compared to 0 visits will cost the same amount. Provider is at risk if patient requires more care than what is being paid for.
Fee for service (FFS): insurer at risk
Why? Provider trades lower FFS rates in exchange for being in-network. Concern is if patient is receiving quality care.
What are the three parts do Medicare and what do each of them cover?
Part A: inpatient hospital care (room, medications in hospital), skilled nursing facility, hospice, home health
Part B: Physician services, labs, x-rays, durable medical equipment, some prescriptions, preventative care services
Part D: outpatient prescription medications (not over the counter)
Identify the major cost expenditures within health care.
Hospital care
Health care (personal)
Physician services
Prescription drugs
What is Medicaid's impact on Medicare?
Medicaid pays deductibles, coinsurance, and copayments for Medicare covered services. (Dual eligibility)
What are the three big problems SafeNetRx works to address?
1. Medication affordability
2. Medication waste
3. Environmental harm
What is the main purpose behind value-based health care delivery models?
BONUS: Name the two organizations that are considered value-based care delivery models
Added on to insurance plans (but not an insurance plan itself) to work with health care providers to control costs and improve quality of care
BONUS:
1) ACOs (Accountable Care Organization)
-group of providers that gather to control cost and improve quality care (voluntarily)
-patients DO NOT enroll in but are part of if their PCP is in one
2) Patient- Centered Medical Home (PCMH)
- financial incentives for provider in PCMH
-focuses on patient centered care, physical and mental health care needs, specialty services, home health care, short wait times, evidence-based medicine, and quality assurance
Part A --> pay for the amount of time they stayed out of coverage times 2
example: if you stay out of coverage for 1 year, then you will pay a late penalty on top of the premium for 2 years
Part B --> late penalty added to premium when decided to enroll
Duration of the penalty is for as long as you have part B and amount is dependent on how long you have been without part B coverage
Part D --> late penalty added to premium when decide to enroll
Amount of penalty depends on how long without Part D.
Government related
Clinical services
Home health care
Nursing facilities and retirement homes
In lecture we learned that 10 states do not have the ACA Medicaid Expansion, who is affected by this?
-Individuals with an income below 100% FPL
-Age 19-64
-Being in state that hasn't adopted ACA Medicaid expansion (remember this was shown from required reading with man who didn't have insurance and was going blind)
-Individuals not eligible via traditional Medicaid pathway
Discuss which types of vaccines are covered by Medicare Part B and Part D.
Part B covers:
-flu, pneumococcal, and hep b vaccine for exposure or medium/high risk patients
-patients with ESRD, hemophilia, health care professionals with frequent blood and bodily fluids contact
-covers other vaccines if being used to treat injury or direct exposure
Part D covers:
-hep b for low-risk patients
-covers vaccines in absence of exposure or injury
List the four managed care organizations from lowest to highest cost.
BONUS: Identify if patients within the organizations can receive coverage for seeing an out-of-network providers, payment plan (capitation or FFS), level of restriction (less, mild, high), premium cost (low, mild, high), and if PCP acts a gatekeeper or not.
HMO
-no coverage for out-of-network providers
-typically, capitation
-high restriction
-low premium
-require gatekeeper
POS
-patients can see out-of-network provider
-capitation
-Mild restriction
-mild amount premium
- require gatekeeper
EPO
-no coverage for out-of-network providers
-no gatekeeper required, can see specialists without referral
-mild restriction level
-mild amount premium
PPO
-patients can see out-of-network providers but may pay more
-Fee for service (FFS)
-less restriction
-high premium
-no gatekeeper required
Describe the enrollment period for each Part of Medicare and if this is missed when individuals can later enroll.
Part A
If you don't qualify for premium free, you can enroll (7-month enrollment period)
Note: because there is no premium fee, people do not usually delay enrollment
Part B
initial enrollment period lasts 7 months, if you are not enrolled within that timeline, must wait until GEP (general enrollment period), note: enrolling late will cause penalties
Part D
Initial enrollment period lasting 7 months, if not enrolled during that period, you must wait until open enrollment period (Oct 15th - Dec 7th)
**Helpful to remember: 7-month enrollment period = 3 months before you turn 65 and 3 months after**
List and describe the four payment methods for providers in the US.
1. Per episode/per stay
-payment not affected how long patient is there
-paid to the hospital
2. Per service
-provider paid separate amount for each service delivered
-outpatient or inpatient
-paid to physician through employer
3. Per day (diem)
-"partial hospitalization"
-provider paid one amount for a day
(ie occupational therapy, group therapy, etc)
4. Per service (medication)
-paid per medication
-formula negotiated with insurance (ingredient cost plus dispensing fee)
Compare traditional Medicaid eligibility with ACA Medicaid expansion.
In traditional:
-applicants must typically meet one of several traditional criteria like being elderly (65 and above), young children, parents, pregnant women, disabled, or blind (note: each a % below the FPL)
-adults without children do not apply
-states make "cutoff" limits
In ACA Medicaid expansion:
-extended to adults aged 19-64 who are not eligible via traditional pathway
-addresses gap for low-income adults without children who were previously excluded
-states choose if they want to permit this way (10 states have not adopted the ACA expansion)
-required cutoff is 138% FPL
-eligible for those below 138%
-federal government pays a higher percentage which incentivizes states to join ACA expansion
Describe the three types of rating within the US private health insurance and identify problems with these ratings.
Experience rating
-Person's premium based on their expected health care costs (more high risk = higher premium)
Take into account: pre-existing conditions, age, gender, smoking, hobbies, and job type
Problem: people who are high risk cannot afford premiums, administrative costs are higher due to underwiring (access individuals risk)
Pure Community Rating
-Person's premium is based on the average health risk in their geographic area
Problem: adverse selection, healthy people drop out (may pay more than their healthcare costs, insurers try to discourage sicker people from buying insurance)
Modified Community Rating
-Insurance sets premiums using SOME risk factors (age, health behaviors) but are not allowed to use health status to set premiums
Problem: people may not be able to afford their premiums, some adverse selection
Advantage: may incentivize employees to be healthier (vaccine incentives)