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week_6_lecture.pptxMedicaid Managed Health Care, The Military Managed Care Health System and Managed Care in a Global Context
WEEK 6 LECTURE
History of Medicaid
Health coverage for the uninsured for over 45 years.
Entitlement program established in 1965 as part of President Johnson’s “Great Society”
Initially intended as a health coverage supplement for those receiving cash assistance (predominantly women of child bearing age and children).
Overtime, Congress has expanded eligibility substantially to fill coverage gaps left by private insurance. Therefore, States have expanded their programs by
(1) raising the income eligibility levels for aid categories; and
(2) adding and/or expanding new populations.
Medicaid pays for nearly 40% of all newborn deliveries and covers 1 in 4 children.
Medicaid now provides benefits to more people than any other public or private insurance program, including Medicare.
History of Medicaid
When the Balanced Budget Act (BBA) was passed in 1997, it created Title XXI or the State’s Children Health Insurance Program (SCHIP)—a grant in aid statute, expanding eligibility for States to cover uninsured children who did not qualify for Medicaid
Incentives (FFP) given to States increased the opportunity for more children to receive “medical assistance”
From Dec 1999-Dec 2010, the SCHIP enrollment has grown from 2.7M to approximately 8M consumers
Medicaid enrollment increased from 31.7M consumers in June 2000 to 58M in 2010
Access to Care Barriers
In 2009, consumers covered by Medicaid and private insurance appear to have an equally low percentage of no usual source of care when compared to the uninsured.
The evaluation of benefits reveals that only 60% of the covered services are federally mandated
Managed Medicaid
First generation programs targeted the “Syndrome”:
Guarantee medical home
Impose structure, coordination, management on care seeking and delivery
Promote primary and preventive care to extent possible given episodic eligibility of beneficiaries
Enroll low income women and children rather than disabled and chronically ill
Principal Current Managed Care Models
HMO/prepaid health plan
Initially voluntary, later mandatory
Primarily in urban areas, some statewide
Mix of commercial and Medicaid-only plan initially, but
Current trend toward Medicaid-only plans
Primary Care Case Management (PCCM)
Similar to primary care gatekeeper, but PCP authorization not always required
Typically, state agency managed
Usually fee-for-service w/ care management fee
Recent efforts to add additional features
Private Health Plan (PHP) or Health Insuring Organization (HIO)
Terms use is variable and inconsistent
Refers to a private vendor managing the program
Uses a few managed care elements such as precertification
Pharmacy benefits usually managed separately by state using “favored nation” pricing
TRICARE
TRICARE is a federal program that provides health care coverage to active duty military and their families as well as retired military and their families.
Available worldwide
Managed in three US regions (North, South, West) and one overseas region
Includes multiple plan options
TRICARE Standard
TRICARE Extra
TRICARE Prime
Active duty service members and activated Guard or Reserve members must enroll in TRICARE Prime, the managed care option.
Active duty family member, retirees and their family members can enroll in any option.
TRICARE Prime includes regional carriers plus a handful of US Family Health Care plans.
TRICARE does not just fund care, it also provides healthcare services through military treatment facilities (MTFs).
TRICARE Benefits Levels
TRICARE Standard
Formerly referred to as CHAMPUS
Allows access to most doctors and hospitals
Higher deductibles and coinsurance than other TRICARE options
Patients can be balanced billed for charges not paid by the program
TRICARE Extra
Limits access to Preferred Providers
Deductibles and coinsurance apply but usually lower than TRICARE Standard
Patients cannot be balanced billed
TRICARE Benefits Levels
TRICARE Prime
The managed care option
Active duty service members and activated Guard or Reserve members must enroll in TRICARE Prime but can choose one of three options:
Military Treatment Facility (MTF) option requiring enrollees to obtain care only from a specified military treatment center
Regional Contractor option for health care provided by one of three regional contractors serving various parts of the US: North, South, and West
US Family Health Plan option limiting care to a specific US Family Health Plan
TRICARE
Benefits for TRICARE Prime in each of the three regions for care that is not provided by military providers or treatment facilities, are administered by private managed care contractors.
Contractors must compete with other qualified MCOs every three years to be the manager for one or more regions.
Only one private company manages a region at any one time.
Private Insurance Internationally
Only a few countries in the world have a national health system based primarily or heavily on multiple private insurers.
Among high-income countries, a national system based primarily on multiple private insurers exists only in the United States.
Even in the United States, public sources account for 45 percent of health expenditures nationwide.
Roles for Private Health Insurance Globally
As a “primary” plan or substitute for public programs (i.e. enrollees opt out of the public system)
As a complement to public programs (i.e. out-of-pocket costs incurred under the public system are reimbursed)
As a supplement to public programs (i.e. services not covered under the public system are reimbursed; care from private providers is reimbursed)
Exporting Managed Care
In middle-income countries with a growing middle class, MCOs can play a complementary role:
Upper and middle class citizens can purchase private plans, while the public system focuses on low-income groups.
Concerns:
Potential to undermine the solidarity of public programs, and the creation of two-tier systems.
Lack of private sector regulation.
Introduce competing MCO-like plans: Private insurance organizations can compete with social insurance.
Complementary or supplementary insurance for high/middle income groups who want greater coverage or fast access to elective services (e.g. Australia, France).
Incorporate managed care techniques such as utilization and care management tools into existing government systems (e.g. United Kingdom).
Looking Forward
Role of private plans as the primary source of insurance is likely limited to low/middle income countries.
In high income countries, private health insurance can serve complementary or supplementary roles.
Even if no role for private health insurance exists, managed care tools can be adopted within local provider and administrative organizations.
Framework for Assessing Managed Care Readiness
Health financing and organization infrastructure in a country determines which U.S. managed care tools can be applied:
Degree of central/regional government control
Autonomy of private health plans
Choice of health plan
Choice of provider
Degree of provider integration and organization
Degree of provider-directed financial controls and incentives
