Discussion 10.2: Tort Reform
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9781284069754_SLID_CH22.pptxChapter 22
Managed Care
&
National Health Insurance
Learning Objectives
Describe the common models of managed care organizations.
Describe the purpose and process of utilization review.
Describe the purpose & various titles of the Patient Protection and Affordable Care Act of 2010 (PPACA).
Describe the various court rulings involving PPACA.
Managed Care
Process of structuring or restructuring the healthcare system in terms of financing, purchasing, delivering, measuring, & documenting broad range of healthcare services & products.
Constraints of Managed Care Organizations
Limitations on the choice of providers by the consumer.
Requirements for prior authorization in order to obtain services.
Managed Care Models
Health Maintenance Organizations (HMOs)
Preferred Provider Organizations (PPOs)
Exclusive Provider Organizations
Point of Service Plans
Experience-Rated HMOs
Managed Care Models (cont’d)
Specialty HMOs
Independent Practice Associations
Group Practice
Group Practice Without Walls
Managed Care Models (cont’d)
Physician Hospital Organizations
Medical Foundations
Management Services Organizations
Vertically Integrated Delivery System
Horizontal Consolidations
Managed Care (cont’d)
Federally Qualified HMOs
State Laws
Case Management Firms
Third-Party Administrators
Managed Care Utilization Review
Utilization Review
Prospective
Concurrent
Retrospective
Utilization Management Firms
Negligent utilization review decisions
Managed Care (cont’d)
Liability for Nonparticipating Hospitals
Employee Retirement Insurance Security Act
Reducing Exposure to Liability
Health Care Quality Improvement Act (1986)
Open enrollment
Emergency care
Ethics in Patient Referral Act (1989)
Managed Care Legal Actions
Financial Incentives Disclosed
Insurer & Tort-feasor
Benefit Denials
False & Misleading Statements
Managed Care Price Fixing
Occurs when two or more competitors come together to decide on a price that will be charged for services or goods
Considered a per se violation of the antitrust laws
Managed Care Market Power
Product Market
Geographic Market
Provider Exclusion
Antitrust & Market Share
National Health Insurance PPACA
Congress, after months of contentious debate, by a slim margin enacted the Patient Protection and Affordable Care Act (PPACA).
PPAC
Increases the number of Americans covered by health insurance & decreases the cost of insurance
Eliminates discriminatory acts, such as exclusions due to preexisting conditions, health status, & gender
PPACA Reforms Immediately in Place
Eliminates lifetime & unreasonable annual limits on benefits
Prohibits recessions of health insurance policies
Provides assistance for those who are uninsured because of preexisting conditions
Requires coverage of preventative services and immunizations
PPACA Reforms Immediately in Place (cont’d)
Extends dependent coverage up to age 26 years
Develops uniform coverage documents so consumers can make equal comparisons when shopping for health insurance
Caps insurance companies’ nonmedical, administrative expenditures
PPACA Reforms Immediately in Place (cont’d)
Ensures consumers have access to an effective appeals process and provide a place to turn for help navigating the appeals process and assessing their coverage
Creates a temporary reinsurance program to support coverage for early retirees
Establishes an Internet portal to assist Americans in identifying coverage options
Facilitates administrative simplification to lower health system costs
PPACA Act Titles
Title I. Quality Affordable Health Care for All Americans
Title II. The Role of Public Programs
Title III. Improving the Quality and Efficiency of Health Care
Title IV. Prevention of Chronic Disease and Improving Public Health
Title V. Health Care Workforce
PPACA Act Titles (cont’d)
Title VI. Transparency and Program Integrity
Title VII. Improving Access to Innovative Medical Therapies
Title VIII. CLASS Act
Title IX. Revenue Provisions
Title IX. Strengthening Quality, Affordable Health Care for All Americans
PPACA Challenged Supreme Court 6/28/12
Agreed that the requirement for nearly all Americans to buy health insurance
Court excised part of law requiring states to expand their Medicaid coverage in a joint federal–state effort, to families with incomes up to 133% of the federal poverty level (FPL)
Affordable Care Act Controversy Continues
Politicians, Insurers, & Policyholders
Increasing Number of Insurance Companies Not Participating in High Risk Markets
Excessive losses due to lower enrollment numbers
More costly medical conditions participate
Less costly do not participate
Increasing insurance premiums
Veterans Administration
The Veterans Administration
Provides care for 8.76 million Americans.
System problems include
Long waits for care
Falsified records
Veterans’ Healthcare Bill
Makes it easier to access health care benefits
Provides for more health professionals
Disciplines VA executives who are negligent
Review Questions
Discuss the purpose and various titles of the Patient Protection & Affordable Care Act of 2010 (PPACA).
Describe the various court rulings involving PPACA.
Describe the common models of managed care organizations.
Review Questions (cont’d)
Describe the purpose & process of utilization review.
Why did Congress pass the Health Care Quality Improvement Act of 1986?
What is price fixing?
