- for years, sheltered from the rising $ of health care

*Americans used the system w/o restrictions & awareness of cost

*providers did not feel constraints to contain costs or hold back services

- System that integrates the $ and delivery of health services

- umbrella term used to describe organizational structures that link financing & health care services

- managed care & prepayment systems

- growth of managed care expedited by employed concerns about costs & ERISA exemptions that prevented states from regulating employer sponsored self-insured plans

- HMO: organizations that serve beneficiaries for a fixed fee & provide both financing & delivery of services

*form of managed care

- Managed care: interdependent btwn payment & services

QUALITY IMPROVEMENT!

1. limited access to the universe of providers

2. payment mechanism that reward efficiency

3. enhanced quality control of procedures

- have a panel of health care providers that are contracted w/ or employed by the MCO

- limiting the providers creates competition in areas of heavy MCO concentration

- panels can be open OR closed

*OPEN: any provider who agrees to terms can join the panel

*CLOSED: select # of participants

- panels go through credentialing process that revieqs:

a. Education

b. clinical experience

c. professional behaviors

- authorization of services: often primary care physicians serve as gatekeepers

Managed care principles cont'd: 2. Payment mechanisms that reward efficiency

- providers are reimbursed for their services through a variety of ways

- providers assumes either some or all of financial risk

*DISCOUNTED FEE SCHEDULE: provider accepts contracts that is <full charge for pt's prescribed plan (insurer holds most risk)

*BUNDLE PAYMENT SYSTEM: pay one fee for set of services; payment made for entire visit or day inclusive of all procedures (less risk on insurer, more risk on provider)

*CAPITATION: separates payment from treatment; may withhold treatment if only certain amount to provider ($ risk to provider)

- MCOs perform utilization review, clinical pathways, benchmarking, & case mgmt functions

- case managers: coordinate all aspects of pt care

*collaborate process of assessment, planning facilitation, care coordination, eval & advocacy for options & services to meet individuals & family's comprehensive health needs through communication & available resources to promote quality cost-effective outcomes

- Therapy benefit managers: intermediary btwn pt/therapists & insurer/MCO

*eval the appropriateness of therapy

*employed by companies that contract with MCOs

1. Aggregation

2. Managed indemnity

3. preferred provider organiztion (PPO) (most common)

4. health maintenance organization (HMO)

5. Point of Service

6. Consumer-directed health plans

7. high deductible health plans (HDHP) (recent increase)

= extent of integration btwn financial & delivery components

*more aggregated= bundled payments

*less aggregated: discounted fee for service

- least aggregated form

- fee for service reimbursement w a pre-authorization component & utilization review

- beneficiary must get pre-authorization but have max choice of providers & fewer restrictions on amnt & type of services

- contract btwn provider & purchasers of health care/MCOs

- plans use pre approval, utilization review, discounted reimbursement

- providers have ^ pool of patients, low financial investments, & more autonomy

- beneficiaries have choice of providers within panel

- PPO= primary employee-based insurance utilizes (approx 69%)

- highly aggregated form of managed care

- utilize gatekeepers/physicians to pre-approve

- utilization review to control costs

- beneficiaries access w pre-approval only, from only those providers in the panel

- provider payment varies: could be fee for service, case based, or capitation (most common)

- hybrid plan containing both HMO & PPO forms of managed care

- beneficiaries chose provider @ time of service

- benefits paid @ increased % within primary care/HMO provider rather than others in panel/PPO

- rules are based on which option pt chooses

- often used w PPO models

- allow individuals greater control over health care utilization & spending

- to discourage overuse of services many require co-payments

- Health Savings Account (HSAs) often used w high deductible health plans (HDHP)

*HSA= amendment to Medicare legislation; account owned by individual helps pay for medical expenses; by employed, but your account

**Employer & person adds amount

- the IRS defines a high deductible health plan as any plan w a deductible of at least $1,300 for an individual or $2,600 for family

- 2017: your out-of-pocket max can be no more than $7,150 for an individual plan and $14,300 for a family plan before marketplace subsidies

- multiple variations exist, no first dollar coverage is allowed

- therapist have to market services bc you have to get a client to WANT to spend $ on services (may have to pay $20 co-pay, may have to pay deductible prior to reimbursement of services)

- growing interest in these plans

Managed care provider structures:

- insurance companies must form relationships w providers (therapist & other health care providers) in order to determine their panels (contracts btwn provider & insurer)

- 4 models of how provider contracts are established:

*staff model

*group model

*network model

*IPA

- less integrated (integration of financial & delivery of services), less structure: more choice

- more integration, more structure: less choice

- providers are employed by the HMO & receive a salary

* some may provider incentives based on performance

**ex/ Kaiser in CA, salaries therapists & physicians, owns hospitals

*beneficiaries receive coverage @ a fixed price per month but must be treated within HMO: highly integrated AKA less choice

- contract w multidisciplinary provider group practices

- some are captive groups

-nonexclusive relationship/independent group

- commonly seen in large multi specialty practices

- HMO: contracts w multiple provider group practices, both primary & specialty

- similar to group model but greater geographical coverage= less integration (more choice)

- IPAs contract w individual providers or small provider groups

- HMO contracts w IPA to provider services to those in the HMO

- providers keep individual & group practices & see pts from multiple HMOs

- most commonly used by private practice OTs and PTs

- result of lack of coverage under private health care & social insurance (Medicare)

- protects personal assets in the event of needing LTC

- medicare only has short term benefits & medicaid req you to spend down assets

- typically have a waiting period

- eligibility is based on loss of function of ADLs or cognition (usually max, usually deductible)

- may cover services @ home, in SNF, ALF and adult day care

- services may include room & board, personal assistance, and personal care (OT)

- 1 in 3 adults will enter nursing home

Worker's Compensation Insurance:

- originate in early 20th century: result of industrial injuries,lost worker wages, worker disability, & workplace litigation

- purpose: protect workers, free employed from excessive litigation & dec the incidence or occupational injuries

- current data:

*4,836 fatal work injuries in 2015

*roadway incidents ^9% in 2015, 26% fatal

- almost half involved in tractor-trailer, truck

- 253 non-roadway fatalities in 2015; most frequent vehicle involved was farm tractor

- farming, forestry, fishing= highest incident of working injury

- sprains & straings 42% of injuries, back pain 11%, carpal tunnel 1%

- employer pays premiums

Worker's Compensation: 3 benefit programs:

1. Health Care insurance

2. Disability income replacement

3. vocational rehav

- benefits start immediately after injury & are unlimited

- med interventions provided until "max med improvement" or return to work

- income replacement after 3-7 days

- cash benefits may be temporary or permanent

- no deductible or coinsurance

- some states allow open choice of provider others must utilize select physicians

- If it is...

*Fatal

*permanent total

*Permanent partial

*temporary total

*temporary partial

- disability benefits paid while worker is not employable

- temporary benefits:paid after 3-7 day wait period

- permanent benefits: provided after max medical improvement obtained

- permanent partial based on schedule of benefits

*schedule injuries: eyes, limbs, ears

*length of time impaired & physical impairment rating

* uses American Medical Association Guides to the Eval of Permanent impairment

- Certain types of permanent partial disabilities are nonscheduled

*injuries to visceral organs, trunk, neck & head, & claims of physiological disability

- Impairment based approach:

* benefit based on severity of impairment not considering future loss of earnings

- Loss of earning capacity approach:

* provides benefits based on estimate on loss future earnings

- Wage loss approach:

* wages assumed loss due to disability & injury

-bifurcated approach:

*impairment approach for workers who return to work & loss of earning for those who cannot work

- fraud & abuse most common

- moral hazards:

*generous benefits encourage employees to file false claims

* ^ cost program incentivize to employees to manage costs & jeopardize med care

* presence of insurance makes employers more safety conscious & employees less safety conscious

*fee for service reimbursement incentives providers to over treat conditions

- automobile insurance includes medical care benefit

- person must be injured in an automobile or home accident to be elligible

- who is at fault determines responsibility

*legal judgement may determine who pays for therapy

- most commonly a fee-for-service reimbursment

- Skills:

*communicate

*effective interventions resulting in pt satisfaction

*do in-house case mgmt to determine LOS, functional status @ d/c, cost of care & pt satisfaction

- Analyze customers & their values:

* MCOs usually value economical, streamline, quality care

* producing outcomes that are functional & sustainable

* market for coverage from several insurers

- Patients advocacy

* improve pt satisfaction to advocate for the pt

- pre-authorizing of adequate treatment amnt, communicate regularly about pt status

- assertive about pt's rights

- appeal process w clear objective documentation