managed care n.
Download
Skip this Video
Loading SlideShow in 5 Seconds..
Managed Care PowerPoint Presentation
Download Presentation
Managed Care

Loading in 2 Seconds...

play fullscreen
1 / 143

Managed Care - PowerPoint PPT Presentation


  • 473 Views
  • Uploaded on

Managed Care. Aaron Liberman, Ph.D. Overview of Managed Care. Techniques of Managed Care vs. Organizations Performing Managed Care Functions. Techniques Financial incentives for providers Promotion of wellness Early identification of disease Patient education Self-care

loader
I am the owner, or an agent authorized to act on behalf of the owner, of the copyrighted work described.
capcha
Download Presentation

Managed Care


An Image/Link below is provided (as is) to download presentation

Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author.While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server.


- - - - - - - - - - - - - - - - - - - - - - - - - - E N D - - - - - - - - - - - - - - - - - - - - - - - - - -
    Presentation Transcript
    1. Managed Care Aaron Liberman, Ph.D.

    2. Overview of Managed Care

    3. Techniques of Managed Care vs. Organizations Performing Managed Care Functions • Techniques • Financial incentives for providers • Promotion of wellness • Early identification of disease • Patient education • Self-care • Utilization management (UR, QI, QM)

    4. Techniques of Managed Care vs. Organizations Performing Managed Care Functions • Organizations • HMO • PPO • EPO • POS Plan • Self-Insured & Experience Rated HMO • Specialty HMO • Managed Care Overlay to Indemnity Plan • PHO

    5. Stages of Managed Care • Early Years: Before 1970 • 1792 Shippers of Boston • 1910 Western Clinic of Tacoma Wash. • 1929 Baylor Hospital’s Prepaid Plan for Teachers (BCBS) • 1932 AMA Adopts Stand Anti-Prepaid Group Practices

    6. Stages of Managed Care • Early Years: Before 1970(cont.) • 1937 Kaiser Foundation Health Plans • 1937 Group Health Association • 1944 HIP of New York • 1947 Group Health Coop of Puget Sound • 1954 First Individual Practice Association

    7. Stages of Managed Care • Early Years: Before 1970(cont.) • Trends • Providers wanted to ensure flow of patients & revenues • Employers began using prepaid plans • Consumers sought access to improved & affordable healthcare

    8. Stages of Managed Care • Adolescent Years: 1970-1985 • 1973 HMO Act • Problems with Federal Legislation

    9. Features of the 1973 HMO Act • Grants and loans to start HMOs • State laws against HMOsoverridden • Dual choice provisions • Indemnity vs. HMO • Employers with 25+ employees must offer 2 HMO plans for every indemnity plan offered

    10. Features of the 1973 HMO Act • Process to become federally qualified • Minimum benefit package • Adequate provider network • QA system in place • Standards of financial stability • Enrollee grievance system

    11. 1973 HMO Act: Importance of Federal Qualification • Good Housekeeping Seal • Use as a marketing tool • Dual choice = access to employer market • Preemption of state insurance oversight • Required for receipt of federal grants

    12. 1973 HMO Act: Problems with Federal Legislation • Compromise between Liberals & Conservatives in Congress • Liberals wanted National Health Insurance • Goal was to increase access to those without access • Conservatives wanted competition • Goal was to promote plans which gave physicians incentives to constrain costs

    13. 1973 HMO Act: Problems with Federal Legislation • Result of the compromise was an open enrollment & community rating system • HMOs were required to accept all enrollees without regard to their health status • Limited the ability of HMOs to relate premiums to health status

    14. 1973 HMO Act: Problems with Federal Legislation • Federal government was slow in issuing implementation regulations • Results of regulation attempts = failures of initial HMOs

    15. Stages of Managed Care • Coming of Age: 1985-Present • Innovation • Maturation • Restructuring

    16. Innovation • PHO as a Contracting Vehicle • Increased negotiating power of providers • Development of Carve Outs • Separated the reimbursement of specific specialized services • Advances Computer Technology • Increased efficiency • i.e. generation of reports, processing of claims

    17. Maturation • HMO & PPO growth • Increased enrollment • External Quality Oversight • NCQA (most credible), URAC, AAAHC, JCAHO • Report Card System • Performance measurement systems • i.e. quality, outcomes, etc. • Focus on Cost Management

    18. Restructuring • Interplay between managed care & delivery system • Dominance of primary care physicians • Consolidation

    19. Health Care Reform

    20. Factors Driving Health Policy Formation • U.S. Budget & Deficit / Surplus • Medicare Trust Fund Shortfall • State Budget Shortfalls • Business Profits & Growth • Excessive • Public Demand & Appetite for Change

    21. Medicare Payment Policies • Packaged Pricing • Case rate method = DRGs • APCs vs. RBRVS • Risk Based Contracting • Fixed monthly amount • Provider Sponsored Organization (PSO) • Provider-based integrated delivery system

    22. Medicaid Payment Policies • Medicaid Managed Care Plans • PCCM • Summary of Principal Efforts • Arizona effort • Virginia effort

    23. Ethics in Managed Care(Fraud, Abuse & Emergence of Federal Legislation) • Relationship to Managed Care • Who are Managed Care Stakeholders • Historical Perspective on Federal Legislation

    24. Historical Perspective: Federal Legislation • Hill Burton Act 1946 • First National Mental Health Commission • CMHC Acts 1963 • Social Security Act 1965 (PL 89-97) • Medicare (Title 18) • Medicaid (Title 19)

    25. Historical Perspective: Federal Legislation • CHP (PL 89-749) • RMPs (PL 89-239) • PSROs 1972 (PL 92-603) • HMO Act 1973 (PL 92-222) • NHRPD Act 1974 (PL 93-641) • ERISA 1974

    26. Historical Perspective: Federal Legislation • OBRA 1981 • Medicare & Medicaid HMOs • TEFRA 1983 • PPS • DRGs • Peer Review Improvement Act 1982 • PSROs • PROs

    27. Historical Perspective: Federal Legislation • DRGs 1985 • COBRA 1985 • Anti-dumping of patients • HCQIA 1986 • National Health Practitioners Data Bank • OBRA 1987 • Nursing home quality care

    28. Historical Perspective: Federal Legislation • TEFRA 1988 • Medicare catastrophic coverage • Expanded Parts A & B • CLIA 1988 • Lab standards classifying the complexity of labs • Medicare Coverage Repeal Act 1989 • Congressional back peddling

    29. Historical Perspective: Federal Legislation • OBRA 1989 • Physician Payment Reform • Resource Based Relative Value Scales (RBRVS) • HIPAA 1996 • Portability of coverage • Restrictions on use of preexisting condition limits • Establishment of MSAs

    30. Contemporary Realizations • Limits on material resources • Limits on health expenditures • Limits on life saving devices • Choices must be made • Oregon legislation • Honest business practices required

    31. Compliance: Federal Statutory Requirements • Purposes of Compliance Programs • Detect & prevent violations • Identify areas of vulnerability • Reduce vulnerability

    32. Compliance: Federal Statutory Requirements • Objectives of Compliance Program • Decrease risk of culpable actions by employees • Reaffirm key organization themes • Quality • Superior Service • Cost effectiveness • Meet legal & statutory requirements

    33. Compliance: Federal Statutory Requirements • Seven Key Steps for Compliance Programs • Establish compliance standards & procedures • Appoint a Corporate Compliance Officer • Delegate discretionary authority • Monitoring, auditing, & reporting • Use of employee hot line

    34. Compliance: Federal Statutory Requirements • Seven Key Steps for Compliance Programs(cont.) • Communicate standards to employees • Consistent appropriate disciplinary procedure • Consistent appropriate responses to violations

    35. Excesses of Managed Care Organizations as Reflected in State Actions to Limit Powers • 14 States: Guaranteed issue & renewal for individual insured • 37 States: Guaranteed I & R group market • 33 States: Restrict pre-ex limits • 20 States: Authorized MSAs • 10 States: Laws increasing consumer access to ER services • 13 States: Require range of added services

    36. Excesses of Managed Care Organizations as Reflected in State Actions to Limit Powers • 15 States: Prohibit Gag Rules • 17 States: Direct access to OB/GYNs

    37. What About the Immediate Future • Legislation on Patient Bill of Rights • Personal Responsibility of Insureds • Individual Ethical Code

    38. Types of Managed Care Organizations

    39. HMO • Both an Insurer & a Delivery System • Primary point of differentiation among HMOs: • How the HMO relates to its physicians

    40. HMO • Staff HMO • Doctors are employees • Form a closed panel • Advantage: • Easier to control • Disadvantages: • Costly & expensive • Limited choice of doctors • Productivity problems

    41. HMO • Group Practice HMO • Contracts with groups of doctors to provide all services to members • Doctors are not employees of the HMO • Captive vs. Independent Model • Captive = doctors provide services exclusively for the HMO • Independent = doctors provide services for both HMO & non-HMO patients

    42. HMO • Group Practice HMO (cont.) • Advantages: • Easier to conduct UM • Lower capital needs than Staff Model • Disadvantages: • Limited choice • Limited locations • Perception of inferior care

    43. HMO • Network HMO • Contracts with more than one practice to provide services • Advantage: • Broader physician participation • Disadvantage: • Still limited choice

    44. HMO • Individual Practice Association (IPA) • Contracts with an association of doctors • Advantages: • Less capital requirements • Broad choice of doctors • Marketing advantages • Disadvantages: • IPA becomes a de facto union for doctors • UM is difficult because doctors have remained in private practice

    45. HMO • Direct Contract HMO • Works directly with large number of doctors • Advantage: • Eliminates possibility of physician bargaining unit by contracting directly with each doctor • Disadvantages: • May assume too much financial risk on behalf of doctors • Difficult to recruit doctors because no clear cut leader

    46. PPO • Common Characteristics of PPOs • Select provider panel • Negotiated payment rates • Typically discounted 20-60% • Rapid payment terms • Utilization management • Failure to comply with plan requirements = financial penalty to physician • Consumer Choice • Higher cost sharing if choose non-panel physician or hospital

    47. PPO • Advantages: • Independence of providers & consumers • Flexibility of plan • Disadvantages: • Little cost control • Lack of provider concern for fiscal integrity of purchaser

    48. EPO • Like PPO except patients may only use panel providers • Advantage: • Control over provider behavior • Disadvantages: • Potentially greater liability exposure for EPO • Disaffection of plan providers

    49. POS Plans • Uses primary care physician as gatekeeper • Primary care physicians are capitated • Withhold is prominently used • Member can use non-panel provider but will pay much higher deductible

    50. POS Plans • Advantage: • Choice accorded patients • Disadvantages: • Added cost to patients • Lack of cost & underwriting control for POS Plan