ECON
bybdh
ch05.pptGetzen’s Health Economics & Financing, 5th Edition
Copyright © John Wiley & Sons, Inc.
Chapter 5: Insurance Contracts and Managed Care
QUESTIONS
Who is the largest health insurer?
Which is better: individual insurance plans, employer-provided insurance, or government insurance?
How is a state mandate to cover alcoholism treatment similar to a tax?
Why are so many Americans uninsured?
Who pays when the cost of medical care rises: employers, employees, government, or insurance companies?
QUESTIONS cont.
How much profit can an HMO make? At whose expense?
What is the underwriting cycle? A retention ratio? A self-insured ASO? ERISA?
Do Managed Care and Health Savings Accounts (HSAs) reduce the cost of health insurance or just shift it around?
Who are the winners and losers in managed care? Do cost reductions mean that some doctors must earn lower incomes? Who are the winners and losers from HSAs?
Does a physician “gatekeeper” or “medical home” work for or against the patient??
5.1 SOURCES OF INSURANCE
- Employer-Based Group Health Insurance
- Medicare
- Medicaid
5.1 SOURCES OF INSURANCE cont.
- State Children’s Health Insurance Program
- Other Government Programs and Charity
- The Uninsured
- Insurance Companies are Financial Intermediaries
- Risk Bearing: From Fixed Premiums to Self-Insurance
- Purchasing Medical Care For Groups
- Provider Payment Methods
- Fee-for-Service (FFS) Charges, Bundled, Capitation, Carve out, Administered, Negotiated
5.2 CONTRACTING AND PAYMENTS
- Medical Loss Ratios
- Claim Processing
- The Underwriting Cycle
- ERISA, Taxes, and Mandated Benefits
- Other People’s Money: Rising Costs and Mediocre Results
5.2 CONTRACTING AND PAYMENTS
cont.
- Defined Contribution Health Plans
5.3 CONSUMER-DRIVEN HEALTH PLANS: HIGH DEDUCTIBLES AND HEALTH SAVINGS ACCOUNTS
5.4 MANAGED CARE
- Closed-Panel Group Practice HMOs
- IPA-HMOs and Open Contracts
- Managed Care Contract Provisions
- The Range of Managed Care Contracts: POS, PPO, HMO Plan Descriptions
- Provider Networks and Legal Structure
5.4 MANAGED CARE cont.
- Management: The Distinctive Feature of Managed Care
- Contractual Reforms To Control Costs
Total Premiums = (Price × Quantity) + Overhead (load)
5.5 UNRESOLVED ISSUES: SPLIT INCENTIVES, DIVIDED LOYALTIES
Copyright 2013 John Wiley & Sons, Inc.
