CHAPTER REVIEW QUESTIONS WEEK 4

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CHAPTER 21

Managed Care and National Health Insurance

Learning Objectives

Describe the common models of managed care organizations.

Describe the purpose and process of utilization review.

Describe the purpose and various titles of the Patient Protection and Affordable Care Act (ACA) of 2010.

Describe the various court rulings involving ACA.

Managed Care

Process of structuring or restructuring the healthcare system in terms of financing, purchasing, delivering, measuring, and documenting broad range of healthcare services and 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 (1 of 3)

Health maintenance organizations (HMOs)

Preferred provider organizations (PPOs)

Exclusive provider organizations

Point-of-service plans

Experience-rated HMOs

Managed Care Models (2 of 3)

Specialty HMOs

Independent practice associations

Group practice

Group practice without walls

Managed Care Models (3 of 3)

Physician–hospital organizations

Medical foundations

Management services organizations

Vertically integrated delivery system

Horizontal consolidations

Managed Care

Federally qualified HMOs

State HMO laws

Case management firms

Third-party administrators

Utilization Review

Utilization review

Prospective

Concurrent

Retrospective

Utilization management firms

Negligent utilization review decisions

Managed Care

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)

Legal Actions

Financial incentives disclosed

Insurer and tort-feasor

Benefit denials

False and misleading statements

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

Market Power

Product market

Geographic market

Provider exclusion

Antitrust and market share

National Health Insurance: ACA

Congress, after months of contentious debate, by a slim margin enacted the Patient Protection and Affordable Care Act (ACA).

ACA:

Increases the number of Americans covered by health insurance and decreases the cost of insurance

Eliminates discriminatory acts, such as exclusions due to preexisting conditions, health status, and gender

ACA: Reforms Immediately in Place (1 of 3)

Eliminates lifetime and 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

ACA: Reforms Immediately in Place (2 of 3)

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

ACA: Reforms Immediately in Place (3 of 3)

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

ACA: Act Titles (1 of 2)

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

ACA: Act Titles (2 of 2)

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

ACA Supreme Court Challenge 6/28/12

Requirement for nearly all Americans to buy health insurance is permissible under Congress’s taxing authority.

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).

ACA Controversy Continues

Politicians, insurers, and 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 healthcare benefits

Provides for more health professionals

Disciplines VA executives who are negligent

Review Questions (1 of 2)

Describe the common models of managed care organizations.

Describe the difference between a vertically integrated delivery system and a horizontal consolidation healthcare delivery system.

Describe the purpose and process of utilization review.

Describe the various titles of the ACA.

Review Questions (2 of 2)

Describe the various court rulings on the ACA.

Describe the purpose of price fixing as discussed in this chapter.

CHAPTER REVIEW QUESTIONS WEEK 4

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