Drennan Topic 7 Hmo Only

Front 1

HMO two roles

Back 1

• Assumes financial risk "risk bearer or insurer"
• Provider of HCGS

1. Provide HC directly or arrange for prevision of care through one/more contract

Front 2

HMO financial risk for over utilization

Back 2

• HMO bears risk
• Payer + provider
• Providers HCGS are at financial risk for over utilization

Front 3

Staff Model HMO

Back 3

• e.g. Kaiser plans- "REAL HMOs"

• "closed pannel" plan- only can go to these

Front 4

How Staff Model HMOs Work

Back 4

• Doctors practice in a group setting (everything is usually in one place)

• HMO employees these doctors full-time- paid by salary- (only work for Kaiser)

• Often own their own hospitals only staffed by their doctors

Front 5

Problem with Staff Model HMO

Back 5

if you join you have to change providers

Front 6

Incentives for utilization with physicians

Back 6

• None
• could be problem with under utilization

Front 7

How to fix problems with under utilization in staff model HMO

Back 7

• Utilization Review (UR) of practice patterns - Quality of care

• Incentive bonuses used to modify salary

Front 8

Staff model HMO utilization incentive bonuses are tied to:

Back 8

• Patient satisfaction survays
• Proper treatment protocol
• Treatment outcomes
• Quality standards

Front 9

Group Model HMO

Back 9

• HMO enrolls individuals

• Physicians practice in a group setting (together)

• Doctors are not employed directly by the HMO (EE or have equity of group practice)

• Closed Pannel

Front 10

Group Model HMO contracts

Back 10

HMO contract with one/more existing group practices to take care of HMO patient

Front 11

Problem with Group Model HMO

Back 11

• In some cases Group practice was formed to take care of HMO patients but takes care of non-HMO as well.
  

• Non-HMO pay more so doctors may take them first and HMO patients may have trouble accessing HC (Conflict of Interest)

Front 12

SEE CHART

Back 12

SEE CHART

Front 13

Payment arrangements Group Model HMO

Back 13

• HMO pays group.
• Group pays doctor

Front 14

HMO payment arrangements to Group

Back 14

• Pays group via capitation payments (per persons)
  

• HMO pays $x/per member/per month

Front 15

In exchange for $x for HMO group has what responsibilities?

Back 15

Group accepts responsibility to pay provider an agreed upon set of services

Front 16

$x^4 Global Capitation

Back 16

• Capitation for:
  
• Out patient + Lab work+ x-ray+ referrals+ hospitalization
  

• Group practice gets more money from HMO

Front 17

$x^3 Capitation

Back 17

• Out Patient +Lab work+ x-ray+ referrals

Front 18

$x^2 Capitation

Back 18

Out Patient + Lab work +x rays

Front 19

$x^1 Capitation

Back 19

• Out Patient ONLY
  
• Gets little money bc HMO must pay for what is not capitated

Front 20

Group Model HMO Premiums

Back 20

• HMO costs premiums and shifts admin cost based on capitation
  

Front 21

Cap rate ($X)

Back 21

• Cap rate ($x) is based on expected utilization of service not actual
  

• FFS actual utilization

Front 22

Cap rate is a function of

Back 22

• Benefits covered in capitation agreement\
  
• More capitation the higher the rate
  

• Demographics of covered population

• Cap rate should be risk adjusted

Front 23

HMO shifts risk to G.P. for capitation service

Back 23

• G.P. has become "insurer"
• G.P. often has to buy stop loss insurance

Front 24

Group Model HMO compensation between G.P. and Individual doctor

Back 24

• Doctors paid by FFS with a "with-hold" account
  

• Doctor does fee for $20 paid %80- %20 goes in account until later

Front 25

With-hold account

Back 25

• funds from all doctors
  

• Funds at risk and doctors are collectively at risk for over utilization as a hole.

• Physicians monitor peers

Front 26

Problem with "with-hold" accounts

Back 26

• Possible incentives to under utilize

• HMOs should develop strong UR and data feed back mechanism to ensure quality standard maintained.

Front 27

Variation in payment in Group Model HMO

Back 27

• Pay individual doctor by individual capitation
  

• 10 doctors in group $2000/10 per month

• Dont see this often