(Health Sys) M3 - Risk & Reimbursement

healthcare provided and financed by gov (from taxes)

Great Britain, Spain, most of Scandinavia, New Zealand, Hong Kong, Cuba

healthcare provided as insurance paid jointly by employers and employees (payroll deduction)

Germany, France, Belgium, Netherlands, Japan, Switzerland, most of the US

healthcare provided by private providers/hospital, paid by gov insurance program (all citizens contributes)

Canada, Taiwan, South Korea

healthcare in Great Britain

pros/cons healthcare in Great Britain

healthcare in Japan

pros/cons healthcare in Japan

healthcare in Germany

pros/cons healthcare in Germany

healthcare in Taiwan

pros/cons healthcare in Taiwan

healthcare in Switzerland

pros/cons healthcare in Switzerland

risk outcomes that are insurable/covered, must include the following–
1. Chance of occurrence can be accurately estimated
2. Event must be irregular (on individual basis)
3. Event must result in a substantial loss
4. Said loss must be measurable
5. Person with loss should have insurance plan

ppl with low risk of illness less likely to buy insurance, results in pool of high risk and cost pts

- Group policies
- Waiting periods
- Medical underwriting (incentivizes low risk pts)
- Coverage limitations (lowers risk in high risk pts)

- Dr’s can create demand for services they supply (especially physician-owned hospitals)
- Can order unnecessary procedures for $$

- Capitation
- Diagnostic related groups (DRGs)
- Global payment models

- Supplier can create demand for services they supply
- Drug/procedure ads targeted towards pts can convince unnecessary demands

- Utilization management
- Prior authorizations from Dr’s can ensure pt truly needs the drug

- One entity makes decision on behalf of another person
- Dr’s makes clinical decision for pt, but isn’t the one paying for it (might not consider financial constraints)

Price transparency and education (so pt is aware to decide)

- When price of service decreases, demand increases
- Ppl with health coverage may have more risky behavior

- Cost sharing
- Pt still responsible for costs, bills can incentivize unrisky behavior

- RCT experiment, assessed effects of cost sharing on health
- Methods: participants assigned to 1 of 5 plans w/ diff co-ins (cost sharing vs fee-for-service models)
- Results: pts with cost sharing plans had less Dr visits, hospitalizations, prescriptions, treatments per yr, worries; no change in health

- natural experiment, assessed effects of having health coverage
- Methods: 10k pts were enrolled in the Oregon Health Plan in a lottery system
- Results: higher use of preventive care services, Dr visits, happiness; no change in health

procedures/actions a healthcare professional is allowed to do under their license

allows provider to delegate certain prescribing duties to pharmacists under negotiated conditions

defines the specific prescribing duties pharmacists are allowed to do, agreed by the provider and pharmacist

agreement only applies to the individuals present at the agreement meeting (can be more than 1 pharmacist/provider)

agreement can apply to everyone (pharmacist/provider) in the organization

- CPAs are called CDTMs (collaborative drug therapy management agreements)
- CDTMs in Oregon are “Patient-Specific CPAs” and requires documentation of pt referral to pharmacist for each person

certain drugs/devices pharmacist can prescribe without a CPA/provider approval

- Formed Public Health and Formulary Advisory Committee
- Makes recs to Board on what drugs/devices pharmacists can prescribe/dispense
- You can submit a form with pharmacy suggestions/ideas to the Board to consider

allows Medicare pt’s to receive their benefits from a private plan, instead of Original Medicare (FFS)

- Insurance company pays Dr for each service pt used
- ex: EGHPs, exchange plans, Original Medicare, some Medicaid

- Insurance company pays fixed/flat fee per pt (even if service not used)
- ex: capitation, DRGs

- Insurance company pays Dr for each service, but payment depends on quality/cost of care
- ex: bundled payment system, ACOs, pay for performance

- rates the quality of care for each health insurance plans, affects reimbursement
- All posted ratings for the year are based on data from 2 years before
- Score is calculated thru several topics (48 total)

1. Allows you to compare health plans
2. Gives insurance companies access to special enrollment periods (can enroll more pts)
3. Used to calculate bonus payments for high quality plans (gov gives more
4. Used to penalize low quality plans

fixed payment CMS (fed gov) pays the MA plan per month per pt enrolled, amount depends on base rate

- the $$ CMS (fed gov) pays the private insurance company monthly for covering Medicare patients
- $$ amount is the lower amount btwn plan bid and benchmark

- $$ the insurance company asks for providing coverage for that plan/pt
- Accounts for the plan’s estimated administrative costs, medical service costs, and profits
- Admin. costs and profits cannot be more than 15% of total plan revenue (so there’s enough dedicated to funding pt’s benefits)
- Part D services is calculated separately

- $$ CMS intends to pay the insurance company for providing care in a specific location
- Amount differs for each county bc CMS decides which location needs more care
- Based on geographics, demographics, avg Medicare spending at the county
- This is why you need zipcode for Medicare plan finder

- extra $$ CMS adds to the base rate payment for high quality care

- Bonus payments for 4-5 stars: extra 5%
- Bonus payments for 3 stars: extra 3%

- plans that bid under the benchmark receive extra $$
- Rebate $$ given is a percent (~50-70%) of the difference btwn the bidenchmark
- Plans with higher star rating/quality gets a higher rebate amount

- modifies the base rate to reflect each enrollee’s health status
- Lower risk score = pt’s expected costs are lower than avg
- Ensures capitated payments for insurance company accounts for the expected cost for each patient

- system of delivering care (patients) and receiving payments (insurance company)
- Penalizedewarded for negative/positive outcomes
- ACOs diff from CCOs, but very similar and will be used interchangeably for the scope of this class

manages health network and facilities for veterans

gives certain benefits and services to veterans and families

manages cemeteries and burial services for veterans

- Served in active military/navy/air service (honorable discharge)
- Enlisted after 9/7/1980 or entered duty after 10/16/1981
- Current/former member of the Reserves/National Guard
- Exposed to toxins/hazards while serving

each disability is rated as % of impact (has protocol), all disabilities are used in a chart to calculate a total scoreating

- Enrolled in or eligible for VA healthcare
- Obtained approval from the VA healthcare team before care

Also at least one of the criteria in the additional list
- service isn't provided or not at needed standard at any VA facility
- state doesn't have full service VA facility
- in-network care isn't in best medical interest
- nearest VA facility over 40 mi distance requrement and lives in {AL, MT, ND, SD, WY}
- nearest VA facility over 30 min drive

- veterans with disability ratings of 10%+ and/or in Priority Group 1 have no copay
- veterans with disability ratings of less than 10%+ have copay for non-service related conditions
- Priority Group 2-8 have copay for OTC and non-service related prescriptions

- affects access to and cost of care
- Changes for person if income changes or service-connected disability worsens

- awarded due to disability/death in active military service
- Establishes eligibility for VA benefits

- highest military decoration awarded for gallantryisk above and beyond call of duty
- Priority Group 1

- awarded to those wounded/killed in action
- Priority Group 3

- can practice in any US state, regardless of state license
- has prescriptive authority
- get PSLF and Education Debt Reduction Program