for DR.SAMUELSON ONLY!!!!!
frguerradi
week_3_lecture1.pptxPrevention of Disease, Health Plans, Quality Care Management, Accreditation and Performance Measurement, Sales and Marketing
WEEK 3 LECTURE
Three types of prevention
Primary prevention is the prevention of disease before it starts.
Secondary prevention is the early detection of disease, before the disease becomes symptomatic.
Tertiary prevention is the prevention of complications of a chronic disease after the disease is diagnosed.
Comprehensive health plan prevention program
Appropriate member benefits, such as immunizations and screenings
Appropriate member services, such as health risk assessments and behavior change (coaching) programs
Prevention-oriented provider contracts that lead to system improvements
Advocacy for effective public policies, such as increases in the taxes on tobacco products
Public policies that improve health
Increases in taxes on cigarettes
Clean indoor air laws
Requirement for childhood immunizations
“Complete Streets” laws that promote walkable and bikeable communities
Cost vs. Quality
Spending too little results in poor quality
Spending too much actually also results in poor quality
Huge differences in spending do not equate to huge differences in quality
Models for Health Care Quality Management in Managed Care Plans
Donabedian’s classic model of Quality Management1
Structure - Focus on the Context in which Care and Services Are Provided
Example - Physician credentialing criteria
Process - Evaluate the Way in which Care is Provided; Generally limited to data obtainable through MCO’s systems; e.g.: Number of referrals made out of network, Look at whether or not certain services and treatments are being provided; e.g.: Prescribing beta blockers following a heart attack
Outcome – the result of care; Common examples:
Infection rates
Hospital readmission
Return to ICU
Peer review and appropriateness evaluation
Continuous quality improvement
Incorporation of IOM’s six goals as appropriate
Continuous Quality Improvement
Understand customer need
Identify processes and outcomes that meet customer need
Assess performance compared with professional or “best-of-class” standards
Define indicators to measure performance
Establish performance expectations
Monitor performance and compare with expectations
Provide feedback to providers and customers
Implement improvements
Go back to step 1
Accreditation of Managed Care Organizations
Majority of the nation's health maintenance organizations (HMOs) and point-of-service (POS) health plans are accredited.
Accreditation is driven by:
Employer mandates
State and federal government requirements
Consumers use of data and information
Desire by health plans to demonstrate quality objectively as market distinction
Accreditation has expanded beyond HMOs and now includes:
Point-of-Service Plans (POS)
Preferred Provider Organizations (PPO)
Managed Behavioral Health Organizations (MBHO)
Credentialing Verification Organizations (CVO)
Disease Management programs (DM)
Accreditation of Managed Care Organizations (cont.)
Selected provider capabilities such as the use of Electronic Medical Records (EMRs)
Selected provider clinical capabilities such as Diabetes Treatment
Health-related Web sites
Accountable Care Organizations (ACOs)
In addition to accreditation, submission of routine HEDIS® and CAHPS ® performance data is required.
Three primary managed care accreditation organizations are:
National Committee for Quality Assurance (NCQA, which is also responsible for the HEDIS data set and co-responsible for CAHPS)
URAC (formerly known as the Utilization Review Accreditation Commission)
Accreditation Association for Ambulatory Health Care (also known as the Accreditation Association or AAAHC)
Accreditation of Managed Care Organizations (cont.)
Accreditation by any of these three organizations is
Usually sufficient to demonstrate compliance with most state and federal laws and regulations around clinical activities and provider credentialing
Also recognized by Centers for Medicare & Medicaid (CMS) as meeting clinical requirements to offer Medicare Advantage plans for seniors
Joint Commission (JC), formerly the Joint Commission on Accreditation of Healthcare Organizations (JCAHO), used to accredit managed care organizations, but discontinued in 2006 to focus on hospital accreditation.
Types of Organizations Accredited by AAAHC
Ambulatory health care clinics
Ambulatory surgery centers
Birthing centers
College and university health centers
Community health centers
Dental group practices
Diagnostic imaging centers
Endoscopy centers
Federally Qualified Community Health Centers
Indian health centers
Lithotripsy centers
Managed care organizations
Medical Home Organizations
Military health care facilities
Types of Organizations Accredited by AAAHC
Multispecialty group practices
Occupational health centers
Office based anesthesia organizations
Office based surgery centers and practices
Oral and maxillofacial surgeons’ offices
Pain management centers
Podiatry practices
Radiation oncology centers
Single specialty group practices
Urgent or immediate care centers
Women’s health centers
Levels of Accreditation by AAHC
Three Years – highest level of accreditation, meaning organization is in substantial compliance with the standards, and the committee has no reservations about the accuracy of the survey findings
One Year – portion of the organization’s operations are acceptable but other areas need to be addressed
Six Months – organization is in substantial compliance with the standards but has only been in operation for a short time
Denial or revocation of accreditation – organization is not in substantial compliance with the standards
Regulation of Sales and Marketing
States have substantial rules about how fully insured health insurance and managed care plans may be marketed and sold
Does not apply to self-funded benefits plans
Rules include how the product is described, what must be included in the description, what sales and marketing practices are prohibited (e.g., door to door sales) how agents and brokers must be appointed, etc.
States also regulate brokers and agents separately from health plan regulation
States may conduct a “Market Conduct” review if an insurer or HMO is subject to higher than usual complaints
Able to impose penalties and sanctions
States also have substantial rules about how private plans may market and sell Medicaid managed care plans – but usually simply prohibit them from selling, with the state taking on that responsibility
CMS has substantial rules about market conduct for Medicare Advantage plans, similar to state rules and may also impose penalties and sanctions
Health reform calls for very substantial new regulatory requirements
Product Design
Product development refers primarily to benefits design, but can include additional services
Most product development is tweaking around the edges, e.g.
Changing coinsurance, copays, deductible
Changes in coverage limits
Goal is to increase market pull, while addressing cost through behavioral shift (e.g., decreasing use of Tier 3 drugs by increasing co-pays)
Currently
Benefits designs for insured products must meet state requirements
Benefits designs for self-funded plans usually done by Benefits Management Consulting firms, but may be done by health plan administrators
Immune to state mandates and requirements (mostly)
Must comply with IRS and DOL requirements, or will lose pre-tax status
Product Design (cont.)
Beginning 2014
Must comply with Essential Health Benefits or will not be considered a Qualified Health Benefits Plan
Applicable to insured or self-funded
States may add mandated benefits, but must pay the difference themselves for subsidies to individuals and small businesses
How Payers Currently Segment the Market
Commercial group health – i.e., employers offering health benefits to employees, and paying at least part of the cost
Large group market: ~> 2,000 covered lives, usually self-insured, multiple locations
Medium group market: >50 - ~2,000 covered lives, large ones may self-insure, smaller ones usually buy insured products
Small group market: 2 – 50 covered lives (some states allow a group of 1)
Government as employer
Federal, state, municipal, educational systems
Treated as large groups, but have unique characteristics
Commercial individual
Not eligible for group
Not including entitlement programs
Entitlement programs
Medicare Advantage
Managed Medicaid
How Payers Will Segment the Market Beginning 2014
Commercial group health – i.e., employers offering health benefits to employees, and paying at least part of the cost
Large self-funded market: ~> 2,000 covered lives, usually self-insured, multiple locations
Large group market: 101 - ~2,000 covered lives, large ones may self-insure, smaller ones usually buy insured products
Medium group market: 26 – 100 covered lives
Small group market: 2-25 (some states allow a group of 1)
Government as employer
Federal, state, municipal, educational systems
Treated as large groups, but have unique characteristics
Commercial individual
Not eligible for group
Not including entitlement programs
Sold through the Exchange
Entitlement programs
Medicare Advantage
Managed Medicaid
Sales vs. Marketing
Sales and marketing are related but distinct activities
Marketing
Focus is on overall growth goals, strategies and tactics, management of the process
Compensation combination of salary and overall growth goals
Sales
The actual process of selling the MCO’s offerings in the marketplace
Compensation usually heavily weighted towards achievement of sales goals
Fundamental Elements of Marketing
Brand Management
External Communications and Public Relations
Advertising
Employer versus consumer advertising
Examples of media
Television
Radio
Collateral texts: outdoor, direct
Market Research
Lead Generation
Sales Campaign Support
Will be heavily regulated for individual and small group market through the Exchange
Distribution Channels
Consultants
Employee benefits consulting very specialized
Focus is on large groups, some mid-sized groups
Paid flat fee by employer just like any other consultant
Brokers
Sell multiple other products as well
Must be appointed by plan, must meet state requirements
Focus is on individuals, small and some mid-sized groups
Pre-ACA
Health plan pays commission as a percent of premium
Result is that commissions rise at same rate of inflation as medical costs, not as rate of inflation
Accounted for up to half of entire administrative costs of a health insurer!
Post-ACA
ACA’s limits on MLR include all sales and marketing costs as admin costs
Commissions now changing to fixed fees or limits on percentages
Direct sales
Self-service – usually via Internet or direct mail
Governmental agencies that control access
