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192 Cards in this Set
- Front
- Back
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Between 2007 and 2009 what was the rate of increase in uninsured among whites
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In spite of the
expansion of Medicaid, the uninsurance rate for whites increased by about 15 percent. |
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Between 2007 and 2009 how did Hispanics fare with respect to uninsured
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The uninsurance rate among Hispanics was
unchanged, but it had been quite high even in 2007; the number of uninsured Hispanics increased because of population growth |
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What region of US fared best during 2009 recession with respect uninsured
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The Northeast experienced
the smallest effects of the recession, both because the average income in this region is higher than elsewhere in the country and because states in the region have generally had greater expansions of public insurance programs. |
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what region of US had largest growth in uninsured during 2009 recession
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The largest increase in the number of uninsured
people occurred in the South. |
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even though Northeast had least growth in uninsured what was % of decline during recession
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Coverage in the Northeast was
the least affected by the recession because of higher incomes and higher eligibility thresholds for public coverage, yet the number of uninsured people in that region still increasedby 10 percent. |
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During 2009 recession what was rate of increase of uninsured in Midwest?
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The largest percentage
increase in the number of uninsured people was in the Midwest (18 percent), but increases in uninsured populations in the South andWest were also large and began from a higher baseline. |
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What three programs kept numbers of uninsured lower than otherwise would have occurred during 2009 recession - and what was the downside
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The Medicaid and CHIP expansion over the
past fifteen years, as well as provisions of the American Recovery and Reinvestment Act that ensured continuity of eligibility, kept the percentage of uninsured Americans from growing more than it would have otherwise—although at a cost of severe pressures on states’ budgets. |
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what are eight simple ethical principles for allocation of scare resources
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Lottery
First-come, first-served Sickest first, Youngest first Number of lives saved Prognosis or life-years saved, Reciprocity |
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what are advantages and disdavantages of Lottery in allocation of medical interventions -where has it been used?
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Lottery Hard to corrupt; little information about
recipients needed Ignores other relevant principles Military draft; schools; vaccination |
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What advantages and disadvantages in Firstcome-first served in allocation - and where used?
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Protects existing doctor-patient relationships;
little information about recipients needed Favours wealthy, powerful, and well-connected; ignores other relevant principles ICU beds; part of organ allocation |
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advantage/disadvantage Sickest first in allocation
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Sickest first Aids those who are suff ering right now; appeals
to “rule of rescue”; makes sense in temporary scarcity; proxy for being worst off overall Surreptitious use of prognosis; ignores needs of those who will become sick in future; might falsely assume temporary scarcity; leads to people receiving interventions only after prognosis deteriorates; ignores other relevant principles Emergency rooms; part of organ allocation |
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advantage/diadvantage younest first in allocation of scarce medical interventions
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Benefi ts those who have had least life; prudent
planners have an interest in living to old age Undesirable priority to infants over adolescents and young adults; ignores other relevant principles New NVAC/ACIP pandemic fl u vaccine proposal |
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advantage/disadvantage number of lives saved in allocation of scarce medical interventions
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Saves more lives, benefi ting the greatest
number; avoids need for comparative judgments about quality or other aspects of lives Ignores other relevant principles Past ACIP/NVAC pandemic fl u vaccine policy; bioterrorism response policy; disaster triage |
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advantage/disadvantage prognosis in allocation of scarce medical interventions
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Maximises life-years produced Ignores other relevant principles, particularly distributive
principles Penicillin allocation; traditional military triage (prognosis) and disaster triage (life-years saved) |
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advantage/disadvantage instrumental value in allocation of scarce medical interventions
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Helps promote other important values; future
oriented Vulnerable to abuse through choice of prioritised occupations or activities; can direct health resources away from health needs Past and current NVAC/ACIP pandemic fl u vaccine policy |
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advantage/disadvantage reciprocity in allocation of scarce medical interventions
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Rewards those who implemented important
values; past oriented Vulnerable to abuse; can direct health resources away from health needs; intrusive assessment process Some organ donation policies |
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What is an underlying assumption in sickest first allocation of resources?
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Favouring those
who are currently sickest seems to assume that resource scarcity is temporary: that we can save the person who is now sickest and then save the progressively ill person later |
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when is instrumental value likely most important in questions of allocation?
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where a specifi c person is genuinely indispensable in
promoting morally relevant principles, instrumental value allocation can be appropriate. |
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Elucidating, comparing,
and evaluating allocation systems should be a research priority. T or F |
True
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What principles do UNOS allocation systems employ or combine
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They combine three principles: sickest-fi rst
(current medical condition); fi rst-come, fi rst-served (waiting time); and prognosis (antigen, antibody, and blood type matching between recipient and donor). |
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What must society do to fairly allocate scarce resources
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To achieve a just allocation of
scarce medical interventions, society must embrace the challenge of implementing a coherent multiprinciple framework rather than relying on simple principles or retreating to the status quo. |
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QALY and DALY multiprinciple systems neglect
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the importance of fair distribution.
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What is a QALY system of allocation
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quality-adjusted life-years
(QALY) have two parts (table 2). One is an outcome measure that considers the quality of life-years. As an example, the quality-of-life measure used by the UK National Health Service rates moderate mobility impairment as 0·85 times perfect health.66 QALY allocation therefore equates 8·5 years in perfect health to 10 years with moderately impaired mobility.67 |
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Qaly principles and advantages
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Prognosis; excludes save
the most lives Maximises future benefi ts; considers quality of life; used in many existing, quantitatively sophisticated frameworks |
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QALY Objections
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Prognosis; excludes save
the most lives Maximises future benefi ts; considers quality of life; used in many existing, quantitatively sophisticated frameworks |
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Daly Principles
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Prognosis; instrumental
value; excludes save the most lives DALY allocation wrongly incorporates age into the outcome measure, claiming that a year for a younger person is in itself more valuable. Priority for young people is better justifi ed on grounds of distributive justice.41 Also, the use of instrumental value to justify DALY allocation resembles that used in Seattle’s dialysis allocation, which inappropriately favoured wage earners and carers of dependants.7,48 |
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Daly advantages and objections
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Maximises future benefi ts; includes
instrumental value, saving people whose productivity is key to a fl ourishing society Outcome measure disadvantages disabled people; age considered as modifying value of individual life-years, rather than from standpoint of distributive justice; defi nition of instrumental value is too focused on economic worth, and could justify bias towards heads of household and other “traditional” social positions; does not incorporate many relevant principles |
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What principles does Complete Lives allocation incorporate?
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Youngest-fi rst;
prognosis; save the most lives; lottery; instrumental value, but only in public health emergency |
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Complete lives advantages?
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Matches intuition that death of adolescents
is worse than that of infants or elderly; everyone has an interest in living through all life stages; incorporates the largest number of relevant principles; resistant to corruption |
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complete lives objections
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Reduced chances for persons who have lived many years; life-years
are not a relevant health care outcome; unable to deal with international diff erences in life expectancy; need lexical priority rather than balancing; complete lives system is not appropriate for general distribution of health care resources |
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Explicit and public
acknowledgment of allocation strategies would be preferable to this surreptitious and piecemeal approach. T or F |
True
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What is the QALY outsome measure problem
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Even if a
life-year in which a person has impaired mobility is worse than a healthy life-year, someone adapted to wheelchair use might reasonably value an additional life-year in a wheelchair as much as a non-disabled person would value an additional life-year without disability. Allocators have struggled with this issue. |
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Ultimately, QALY
allocation systems do not recognise many What? |
morally
relevant values—such as treating people equally, giving priority to the worst-off , and saving the most lives—and are therefore insuffi cient for just allocation. |
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Explain DALY systems of allocation
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DALY systems also incorporate quality-of-life
factors—for instance, they equate a life-year with blindness to roughly 0·6 healthy life-years.74 Additionally, DALY allocation ranks each life-year with the age of the person as a modifi er: “The well-being of some age groups, we argue, is instrumental in making society fl ourish; therefore collectively we may be more concerned with improving health status for individuals in these age groups.” |
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DALY allocation wrongly incorporates what factor into the outcome measure
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DALY allocation wrongly incorporates age into the
outcome measure, claiming that a year for a younger person is in itself more valuable. Priority for young people is better justifi ed on grounds of distributive justice |
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A complete lives system incorporates what five factors for allocation?
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incorporates fi ve principles (table 2): youngest-first,
prognosis, save the most lives, lottery, and instrumental value. |
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How is a complete lives system complete lives
the appropriate focus of distributive justice |
Many thinkers have accepted complete lives
as the appropriate focus of distributive justice: “individual human lives, rather than individual experiences, [are] the units over which any distributive principle should operate.” |
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The complete lives system discriminates against ?
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older
people |
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Balancing in complete lives system?
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As an
alternative, balancing priority to the worst-off against maximising benefi ts has won wide support in discussions of allocative local justice.1,8,30 As Amartya Sen argues, justice “does not specify how much more is to be given to the deprived person, but merely that he should receive more” |
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What is the goal of complete lives system?
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Ultimately, the complete lives system
does not create “classes of Untermenschen whose lives and well being are deemed not worth spending money on”,91 but rather empowers us to decide fairly whom to save when genuine scarcity makes saving everyone impossible. |
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The health care sectors with the most
rapid growth in cost are - at what rates from 2002-2005 |
The health care sectors with the most
rapid growth in cost are prescription drugs and administrative costs of private health insurance (each increasing at 11% to 16% over the past 3 years). Hospital and physician expenditures have been growing at annual rates closer to 7% to 8% over the past 3 years (3). |
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The federal government projected an average annual
healthcare growth rate of ? through 2013 |
The federal government projected an average annual
growth rate of 7.2% through 2013, with health expenditures (Table) rising from $1.6 trillion in 2002 (14.9% of gross domestic product, the value of all goods and services produced in a nation) to $3.6 trillion by 2013 (18.4% of gross domestic product) |
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What Four major actors occupy the health care stage
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Four major actors occupy the health care stage: purchasers,
insurers, providers, and suppliers |
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What is the fundamentl conflict in healthcare economics and policy?
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Payers want to contain costs; providers and
suppliers resist cost containment. That conflict is the fundamental battle in the health care economy. |
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What are Seven primary perspectives
on why costs are high and how to control their growth. |
Seven primary perspectives
on why costs are high and how to control their growth. While few analysts adhere to only 1 of these views, the perspectives can be grouped into 7 categories. 1. High and rising costs are not such a serious problem. 2. High and rising costs are a problem, but they are created by factors external to the health care system. 3. High and rising costs are caused by the absence of a free market; the remedy is to give patients more responsibility for costs of care and to encourage competition among health insurers and providers. 4. High and rising costs result from medical technologies creating innovation in the diagnosis and treatment of illness. 5. High and rising costs are in part the result of excessive costs of administering the health care system. 6. High and rising costs are explained by the absence of strong cost-containment measures. 7. High and rising costs are the result of the market power of health care providers. |
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In reality, patients do not
purchase physician and hospital services in a free market, as shown by ?. |
1. Patients cannot compare the cost of medical services
because different health conditions lead to widely differing costs. A patient with a headache does not know whether the cost of care will be a $50 physician visit plus a bottle of aspirin or $60 000 neurosurgery for a brain neoplasm. 2. Because most health care is a necessity rather than a luxury, private and government insurance has evolved to shield patients from the financial disaster of serious illness, obviating the need for patients to shop for lower-cost services. 3. A free market might lead to patients becoming more cost conscious, but low-income and sick people who are responsible for all or part of their health care costs may incur unaffordable expenditures and be priced out of receiving needed services. |
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What is thefundamental difference between
the pre- and postselective contracting eras with respect to hospital management. |
In the
former era, hospital competition led to higher costs; in the latter, competition has been associated with lower costs and lower hospital revenues, leading hospitals to respond in an anticompetitive manner through consolidation. |
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In most states who controls healthcare market?
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In all but 14
states, 3 insurers control over 65% of the market; |
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Where the market is controlled by a limited number of players what results with repect to employer premiums?
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their
market clout enables them to negotiate high premiums from employers with scant risk for losing customers |
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Higher concentrations of market share among a few
HMOs are associated with higher HMO profits T or F |
True
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Does managed competition result in lower healthcare costs?
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Because
managed competition has never been implemented, it is not known whether it can control costs (66, 67). |
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What are the majors things the Patient Protection and Affordable Care Act
will accomplish |
Most individuals will be required to have health insurance beginning in 2014.
• Individuals who do not have access to affordable employer coverage will be able to purchase coverage through a health Insurance Exchange with premium and cost-sharing credits available to some people to make coverage more affordable. Small businesses will be able to purchase coverage through a separate Exchange. • Employers will be required to pay penalties for employees who receive tax credits for health insurance through the Exchange, with exceptions for small employers. • New regulations will be imposed on all health plans that will prevent health insurers from denying coverage to people for any reason, including health status, and from charging higher premiums based on health status and gender. • Medicaid will be expanded to 133% of the federal poverty level ($14,404 for an individual and $29,327 for a family of four in 2009) for all individuals under age 65. |
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The Congressional Budget Office estimates that the legislation will reduce the number of uninsured by ?
in 2019 at a net cost of ? over ten years, while reducing the deficit by ? billion during this time period. |
The Congressional Budget Office estimates that the legislation will reduce the number of uninsured by 32 million
in 2019 at a net cost of $938 billion over ten years, while reducing the deficit by $124 billion during this time period. |
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In Thomas More how do Plaintiffs describe their immediate injury?
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Plaintiffs describe their present injury
as being compelled to “reorganize their affairs.” |
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What is the core position of Thomas More plaintiffs with respect to the Commerce clause
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It is plaintiffs’ position that if the Act is found
constitutional, the Commerce Clause would provide Congress with the authority to regulate every aspect of our lives, including our choice to refrain from acting. |
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Under the Commerce Clause Congress may regulate:
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Congress may regulate: (1) “the use of the channels of interstate
commerce,” such as regulations covering the interstate shipment of stolen goods; (2) to protect “the instrumentalities of interstate commerce, or persons or things in interstate commerce,” such as legislation criminalizing the destruction of aircraft and theft from interstate commerce; and (3) “those activities that substantially affect interstate commerce.” United States v. Lopez , 514 U.S. 549, 558-59 (1995) |
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Concerning the third prong of Lopez, under Gonzalez v. Raich, 545 U.S. 1, 22 (2005) what is the level of scrutiny?
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The court need
not itself determine whether the regulated activities, “taken in the aggregate, substantially affect interstate commerce in fact, but only whether a ‘rational basis’ exists for so concluding.” |
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What is the Lopez phrase concerning the application of the COmmerce clause?
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The Lopez Court held that Congress could not “pile
inference upon inference” to find a link between the regulated activity and interstate commerce. Id. at 567. |
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what two key propositions did the Court decide in Lopez?
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the Court concluded that possessing a gun in a school
zone was not an economic activity. Nor was the prohibition against possessing a gun “an essential part[] of a larger regulation of economic activity, in which the regulatory scheme could be undercut unless the intrastate activity were regulated.”Lopez. at 561. |
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How did Thomas More Court apply Lopez?
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Far from “inactivity,” by choosing to
forgo insurance plaintiffs are making an economic decision to try to pay for health care services later, out of pocket, rather than now through the purchase of insurance, Case 2:10-cv-11156-GCS-RSW Document 28 Filed 10/07/10 Page 16 of 20 17 collectively shifting billions of dollars, $43 billion in 2008, onto other market participants. As this cost-shifting is exactly what the Health Care Reform Act was enacted to address, there is no need for metaphysical gymnastics of the sort proscribed by Lopez. |
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What authority did the Thomas More Court cite to support the notion that the Commerce clause enables penalties?
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Congress is
authorized by the Commerce Clause to impose a sanction “as a means of constraining and regulating what may be considered by the Congress as pernicious or harmful to commerce.” Rodgers v. United States, 138 F.2d 992, 995 (6th Cir. 1943) (upholding penalty provision of Agricultural Adjustment Act for exceeding quota of permissible cotton sales as exercise of Congress’s power to regulate commerce, where purpose of statute was not levying a tax but regulating the production of cotton affecting interstate commerce). |
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In the Attys General case the plaintiffs lodged 6 violations of the US constitution - they are
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1) exceeds Commerce clause authority 2) violates substantive due process under 5th A 3) unconstitutional direct tax 4) coercion and commandeers states in vio of 9th and 10th A for Medicare 5) coercion and commandeers states in vio of 9th and 10th A 6) violates state's soverignty
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What did the Attys general case conclude about whether the mandate was a tax
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COngress did not call it a tax even though Congress did enumerate taxes elsewhere within the same bill and Congress did not invoke a revenue generating purpose
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What did the Attys general court say about why the mandate must be evaluated under the commerce clause
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The mandate is a penalty and not a tax therefore comes under Commerce clause
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How does the anti-injunction act figure into the Attys general opinion
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Since the mandate is a penalty and not a tax it does not control
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The attys general case found that just as Us federal Govt can regulate wages in the national labor market ----
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so can the mandate regulate the national healthcare marketplace
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Under attys general case do citizens possess a fundamental right not to enter into contracts that despoils the mandate
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No
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How did the attys general case view the inactivity argument concerning the mandate
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Allowed the action to proceed as a sort of case of first impression
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steps to understand compliance with regulations
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1) what part of reg that rule falls in 2) what statute does the reg link to and 3) what is the policy goal behind statute and reg/rule
What was agency trying to accomplish? |
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other hints for understanding rules
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who wrote it - perspective and what were they trying to accomplish
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what is central goal of course?
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lawyer must understand policy goals to understand structure
does the why of a specific rule comport with the overall why of the statute or reg scheme |
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When a Provider offers the patient a concession are they obligated to offer the same concession to the plan or insurer?
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Yes
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what is essential to understanding a payment system
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policy goals - and how the payment system began - why and how structured - why regulated
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What section is the individual mandate - what statute
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1501 of affordable care act - minimum essential coverage provision
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what does eastern district Virginia argue about commerce clause
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the mandate exceeds that power because it does not meet threshold for substantially affecting interstate commertce
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The next step beyond cost based system is
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a Charge based system like a fixed % of the amount charged
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What is a fee schedule payment system
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Payment to provider based on a fee schedule or a lesser amount actually charged
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What is managed care payment system
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still an FFS apporach but the TPP attempts to manage the care
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How does capitation change an FFS system of payment
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typically a per member per month arrangement
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DRG
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Diagnosis-related Groups
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APC
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Ambulatory payment classification
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RBRVS
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Resource-based Relative Value Systems
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How do users track medicare payment system changes
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Federal Register
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Captialized Carrier refers to who
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Medicare b who usually pays Physician services but carrier can refer to any insurer
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Cost based systems are on the decline or rise
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decline
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Must hospitals cost reports even thought their oayment systems are no longer cost based?
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Yes CMS uses the reports as a part of a complex system to determine costs for several pps like DRGs and APCs
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what is the primary underlying assumption in charge based systems
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That the hospital's charges are uniformly based on the actual costs
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What is discounting in Medicare
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Paying less - 50% - for services subsequent to services for same patient/DOS
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waht are the three components of Relative Value determinations for RBRVS systems
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work, Practice expense for both facility and non-facility, nad medical malpractice
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What are three RVUs for radiology
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Total tech and professional, Professional mod -26, and tech mod -TC
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What is PPS
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The prospective
pricing system (PPS) for hospitals, in which a hospital's payment for patient care is computed in advance on the basis of a formula, rather than retrospectively on the basis of costs incurred |
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What 3 problems with requiring caregivers to ration services
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1)society should not be
permitted to escape its rightful burden by pressing caregivers into involuntarily rationing service. 2, many object to "the juxtaposition of the cost containment mandate and the physician/patient relationship.' 3 M Traditionally, this relationship (as well as that between health facility and patient) has been fiduciary in nature, characterized by the patient's trust and confidence that the caregiver would act only with the patient's best interests utmost in mind. 3 it will health caregivers against their will into a posture that increases their potential exposure to the risk of legal liability. |
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What is best argument for requiring caregivers to ration scarce resources?
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Perhaps the most persuasive argument
for assigning the rationing role to caregivers is to consider the alternatives and to ask who could perform this function better. Do we really want detached government bureaucrats making life and death decisions in the context of resource allocation? |
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mpfs
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Medicare Physician Fee Schedule
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What are the 3 characteristics of any PPS system
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1)Payments a fixed in advance 2) there is a classification system 3) payments are made for categories in the classification systems
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What is rebasing
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annual updating of payment rates for categories in PPS classification system
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recalibration?
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annual updating of relative weight factors in a PPS
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What is the meta-narrative issue for PPS systems
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Medical neccessity - RACs ensure
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What is the CMS formula for an ASC surgical procedure
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lesser of 65% of the APC payment or the non-facility component of the practice expense RVU from RBRVS
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who bears great risk in a capitated system payer or provider
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provider
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what does the mandate do?
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Require U.S. citizens and legal residents to have qualifying health coverage. Those without coverage
pay a tax penalty of the greater of $695 per year up to a maximum of three times that amount ($2,085) per family or 2.5% of household income. |
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Employers Requirement
to offer coverage under ppaca assessment - 3 rules |
1) Assess employers with more than 50 employees that do not offer coverage and have at least one fulltime
employee who receives a premium tax credit a fee of $2,000 per full-time employee, excluding the first 30 employees from the assessment. Employers with more than 50 employees that offer coverage but have at least one full-time employee receiving a premium tax credit, will pay the lesser of $3,000 for each employee receiving a premium credit or $2,000 for each full-time employee. (Effective January 1, 2014) 2) Exempt employers with 50 or fewer employees from any of the above penalties. 3) Require employers that offer coverage to their employees to provide a free choice voucher to employees with incomes less than 400% FPL whose share of the premium exceeds 8% but is less than 9.8% of their income and who choose to enroll in a plan in the Exchange |
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ppaca requirements where > 200 employees
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Require employers with more than 200 employees to automatically enroll employees into health
insurance plans offered by the employer. Employees may opt out of coverage. |
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ppacac effects on medicaid
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Expand Medicaid to all individuals under age 65 (children, pregnant women, parents, and adults without
dependent children) with incomes up to 133% FPL based on modified adjusted gross income |
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ppaca Treatment of CHIP •
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Require states to maintain current income eligibility levels for children in Medicaid and the Children’s
Health Insurance Program (CHIP) until 2019 and extend funding for CHIP through 2015. CHIP benefit package and cost-sharing rules will continue as under current law. Beginning in 2015, states will receive a 23 percentage point increase in the CHIP match rate up to a cap of 100%. CHIP-eligible children who are unable to enroll in the program due to enrollment caps will be eligible for tax credits in the state Exchanges. |
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Small business ppaca
tax credits • |
Provide small employers with no more than 25 employees and average annual wages of less than
$50,000 that purchase health insurance for employees with a tax credit. – Phase I: For tax years 2010 through 2013, provide a tax credit of up to 35% of the employer’s contribution toward the employee’s health insurance premium if the employer contributes at least 50% of the total premium cost or 50% of a benchmark premium. The full credit will be available to employers with 10 or fewer employees and average annual wages of less than $25,000. The credit phases-out as firm size and average wage increases. Tax-exempt small businesses meeting these requirements are eligible for tax credits of up to 25% of the employer’s contribution toward the employee’s health insurance premium. – Phase II: For tax years 2014 and later, for eligible small businesses that purchase coverage through the state Exchange, provide a tax credit of up to 50% of the employer’s contribution toward the employee’s health insurance premium if the employer contributes at least 50% of the total premium cost. The credit will be available for two years. The full credit will be available to employers with 10 or fewer employees and average annual wages of less than $25,000. The credit phases-out as firm size and average wage increases. Tax-exempt small businesses meeting these requirements are eligible for tax credits of up to 35% of the employer’s contribution toward the employee’s health insurance premium. |
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ppaca Reinsurance program •
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Create a temporary reinsurance program for employers providing health insurance coverage to retirees
over age 55 who are not eligible for Medicare. Program will reimburse employers or insurers for 80% of retiree claims between $15,000 and $90,000. Payments from the reinsurance program will be used to lower the costs for enrollees in the employer plan. Appropriate $5 billion to finance the program. (Effective 90 days following enactment through January 1, 2014) |
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ppacac Public plan option •
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Require the Office of Personnel Management to contract with insurers to offer at least two multi-state
plans in each Exchange. At least one plan must be offered by a non-profit entity and at least one plan must not provide coverage for abortions beyond those permitted by federal law. Each multi-state plan must be licensed in each state and must meet the qualifications of a qualified health plan. If a state has lower age rating requirements than 3:1, the state may require multi-state plans to meet the more protective age rating rules. These multi-state plans will be offered separately from the Federal Employees Health Benefit Program and will have a separate risk pool. |
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ppaca Waste, fraud, and abuse •
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Reduce waste, fraud, and abuse in public programs by allowing provider screening, enhanced oversight
periods for new providers and suppliers, including a 90-day period of enhanced oversight for initial claims of DME suppliers, and enrollment moratoria in areas identified as being at elevated risk of fraud in all public programs, and by requiring Medicare and Medicaid program providers and suppliers to establish compliance programs. Develop a database to capture and share data across federal and state programs, increase penalties for submitting false claims, strengthen standards for community mental health centers and increase funding for anti-fraud activities. |
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ppaca improvements Comparative
effectiveness research • |
Support comparative effectiveness research by establishing a non-profit Patient-Centered Outcomes
Research Institute to identify research priorities and conduct research that compares the clinical effectiveness of medical treatments. The Institute will be overseen by an appointed multi-stakeholder Board of Governors and will be assisted by expert advisory panels. Findings from comparative effectiveness research may not be construed as mandates, guidelines, or recommendations for payment, coverage, or treatment or used to deny coverage. (Funding available beginning fiscal year 2010) Terminate the Federal Coordinating Council for Comparative Effectiveness Research that was founded under the American Recovery and Reinvestment Act. (Effective upon enactment) |
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ppaca Medical malpractice •
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Award five-year demonstration grants to states to develop, implement, and evaluate alternatives
to current tort litigations. Preference will be given to states that have developed alternatives in consultation with relevant stakeholders and that have proposals that are likely to enhance patient safety by reducing medical errors and adverse events and are likely to improve access to liability insurance. (Funding appropriated for five years beginning in fiscal year 2011) |
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Three ppaca pilot programs for Medicare •
|
Establish a national Medicare pilot program to develop and evaluate paying a bundled payment for acute,
inpatient hospital services, physician services, outpatient hospital services, and post-acute care services for an episode of care that begins three days prior to a hospitalization and spans 30 days following discharge. If the pilot program achieves stated goals of improving or not reducing quality and reducing spending, develop a plan for expanding the pilot program. (Establish pilot program by January 1, 2013; expand program, if appropriate, by January 1, 2016) • Create the Independence at Home demonstration program to provide high-need Medicare beneficiaries with primary care services in their home and allow participating teams of health professionals to share in any savings if they reduce preventable hospitalizations, prevent hospital readmissions, improve health outcomes, improve the efficiency of care, reduce the cost of health care services, and achieve patient satisfaction. (Effective January 1, 2012) • Establish a hospital value-based purchasing program in Medicare to pay hospitals based on performance on quality measures and extend the Medicare physician quality reporting initiative beyond 2010. (Effective October 1, 2012) Develop plans to implement value-based purchasing programs for skilled nursing facilities, home health agencies, and ambulatory surgical centers. (Reports to Congress due January 1, 2011) |
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Improving Quality/Health System Performance medicaid - ppaca
three programs |
• Create a new Medicaid state plan option to permit Medicaid enrollees with at least two chronic conditions,
one condition and risk of developing another, or at least one serious and persistent mental health condition to designate a provider as a health home. Provide states taking up the option with 90% FMAP for two years. (Effective January 1, 2011) • Create new demonstration projects in Medicaid to pay bundled payments for episodes of care that include hospitalizations (effective January 1, 2012 through December 31, 2016); to make global capitated payments to safety net hospital systems (effective fiscal years 2010 through 2012); to allow pediatric medical providers organized as accountable care organizations to share in cost-savings (effective January 1, 2012 through December 31, 2016); and to provide Medicaid payments to institutions of mental disease for adult enrollees who require stabilization of an emergency condition (effective October 1, 2011 through December 31, 2015). • Expand the role of the Medicaid and CHIP Payment and Access Commission to include assessments of adult services (including those dually eligible for Medicare and Medicaid). ($11 million in additional funds appropriated for fiscal year 2010) |
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Improving quality care ppaca in primary care
|
• Increase Medicaid payments in fee-for-service and managed care for primary care services provided by
primary care doctors (family medicine, general internal medicine or pediatric medicine) to 100% of the Medicare payment rates for 2013 and 2014. States will receive 100% federal financing for the increased payment rates. (Effective January 1, 2013) • Provide a 10% bonus payment to primary care physicians in Medicare from 2011 through 2015. (Effective for five years beginning January 1, 2011) |
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ppaca national quality strategy
|
• Develop a national quality improvement strategy that includes priorities to improve the delivery of health
care services, patient health outcomes, and population health. Create processes for the development of quality measures involving input from multiple stakeholders and for selecting quality measures to be used in reporting to and payment under federal health programs. (National strategy due to Congress by January 1, 2011) • Establish the Community-based Collaborative Care Network Program to support consortiums of health care providers to coordinate and integrate health care services, for low-income uninsured and underinsured populations. (Funds appropriated for five years beginning in FY 2011) |
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ppaca financial disclosure
|
Require disclosure of financial relationships between health entities, including physicians, hospitals,
pharmacists, other providers, and manufacturers and distributors of covered drugs, devices, biologicals, and medical supplies. (Report due to Congress April 1, 2013) |
|
|
ppaca preventive care
|
• Improve prevention by covering only proven preventive services and eliminating cost-sharing for
preventive services in Medicare and Medicaid. (Effective January 1, 2011) For states that provide Medicaid coverage for and remove cost-sharing for preventive services recommended by the US Preventive Services Task Force and recommended immunizations, provide a one percentage point increase in the FMAP for these services. Increase Medicare payments for certain preventive services to 100% of actual charges or fee schedule rates. (Effective January 1, 2011) |
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three point ppaca national wellness strategy
|
• Establish the National Prevention, Health Promotion and Public Health Council to coordinate federal
prevention, wellness, and public health activities. Develop a national strategy to improve the nation’s health. (Strategy due one year following enactment) Create a Prevention and Public Health Fund to expand and sustain funding for prevention and public health programs. (Initial appropriation in fiscal year 2010) Create task forces on Preventive Services and Community Preventive Services to develop, update, and disseminate evidenced-based recommendations on the use of clinical and community prevention services. (Effective upon enactment) • Establish a Prevention and Public Health Fund for prevention, wellness, and public health activities including prevention research and health screenings, the Education and Outreach Campaign for preventive benefits, and immunization programs. Appropriate $7 billion in funding for fiscal years 2010 through 2015 and $2 billion for each fiscal year after 2015. (Effective fiscal year 2010) • Establish a grant program to support the delivery of evidence-based and community-based prevention and wellness services aimed at strengthening prevention activities, reducing chronic disease rates and addressing health disparities, especially in rural and frontier areas. (Funds appropriated for five years beginning in FY 2010) |
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What was CMS's enforcement plan with respect to Hippa related code set implementation in the mid 90s?
|
The enforcement of the
transactions and code sets is primarily complaint-driven. When CMS receives a complaint about a covered entity, they will notify the entity in writing that a complaint has been filed. |
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What is the regulatory distinction between insured and company self-insured plans
|
If an
employee is in an insured plan, the insurer must comply with state benefit mandates, claims-handling standards, privacy rules, and other regulations that are applicable to all health insurers. If the employee is in a self-insured plan, the federal government has regulatory authority under the 1974 Employee Retirement Income Security Act (ERISA). This pre-empts most state insurance regulations, including benefit mandates. |
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What are the five major risk categories for health insurers
|
Asset risk, affiliates — the risk a company’s
investments in affiliates will incur losses ■ Asset risk, other — the risk of default of principal or interest payments and market value fluctuations ■ Underwriting risk — the risk of underestimating existing policyholder obligations or inadequately pricing business to be written in the coming year ■ Credit risk — the risk of recovering receivable amounts from creditors ■ Business risk — the general risk of operating a business |
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What is RBC requirement
|
The adequacy of an insurance
company’s capital and surplus is evaluated by comparing the company’s total adjusted capital and surplus with its RBC requirement. The resulting RBC ratio is used to determine whether regulatory intervention is necessary. It is not used to set a maximum capital and surplus level or a target capital and surplus level. An RBC ratio of 200 percent is considered the minimum level of financial soundness. An RBC ratio of less than 150 percent requires the department to take certain actions, including exercising control of the insurer, depending on the severity of the situation. |
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Claims adjustment expense —
|
Claims adjustment expense — Expenses to record,
adjust, and settle claims. This includes cost-containment expenses that reduce the number of health services provided or the cost of services. Included in this category are salaries of claims personnel. |
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|
General administrative expense —
|
Expenses an insurer
incurs to run its business. This includes all expenses that are not directly attributed to settling and paying claims of members. Examples are commissions, marketing and advertising expenses, and salaries of non-claims personnel. |
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Lines of business (all) —
|
Comprehensive, Medicare
supplement, dental only, vision only, Federal Employees Health Benefit Plan, Medicare, Medicaid, stop loss, disability income, other health, and other non-health. |
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Medicare —
|
Medicare — A federal health insurance program for
people 65 years of age and older, and for people of all ages with certain disabilities. Eligibility is not income based. |
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Medicaid —
|
A federal program that provides health
coverage for certain categories of people with low incomes. |
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|
Medical loss ratio
|
— The percent of health insurance
premiums spent on medical claims. A 0.96 loss ratio means that 96 percent of the insurer’s health insurance premiums purchased medical services. The more technical definition of medical loss is claims incurred divided by net premium earned. |
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Net claims incurred —
|
Cost for hospital and medical
benefits, emergency room, and prescription drugs minus recoveries from the reinsurer plus the change in the unpaid claim liability. The unpaid claim liability is the insurer’s estimate of the cost for claims already reported but not yet paid and an estimate of claims incurred by a member but not yet submitted for payment. |
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|
Net income —
|
The net result of all revenue, claims
incurred, expenses, investment results, taxes, and writeoffs. This report uses the term profit margin as synonymous with net income. |
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|
Net investment income (or gain) —
|
Includes all income
earned from invested assets minus expenses associated with investments plus the profit (or loss) realized from the sale of assets. |
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|
Net premium earned —
|
The amount charged by the
insurer to the policyholder for the effective period of the contract, reinsurance premiums, plus the change in the unearned premium liability. The unearned premium |
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|
Net underwriting gain/loss —
|
Gain or loss after an
insurer pays claims, adjustment expenses, and general administrative expenses. In other words, it is the amount an insurer earns from its insuring activities. When insurers collect more premiums than they pay in medical claims, claims expenses, and administrative expenses, the insurer has an underwriting gain. If the medical claims, claims expenses, and administrative expenses exceed the premiums collected, the insurer has an underwriting loss. |
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|
Premium-to-surplus ratio —
|
This ratio measures an
insurer’s ability to support its existing business, as well as any growth. Since surplus provides a cushion for claims and expenses that exceed what the insurer expected, this ratio measures the adequacy of the surplus cushion available for unexpected claims and expenses. |
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|
Risk-based capital (RBC) —
|
A method for evaluating
an insurer’s surplus in relation to its overall business operations in consideration of its size and lines of business written. An insurer’s RBC is calculated by applying factors to various assets, premium, and reserve items. The calculation produces the “authorized control level.” The RBC ratio is the insurer’s surplus divided by the authorized control level. The state is authorized to take regulatory action against an insurer that fails to maintain surplus equal to 200 percent of its authorized control level. |
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|
Reserves —
|
Funds created to pay anticipated claims.
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|
Surplus —
|
The amount an insurance company’s assets
exceed its liabilities. Additional funds are surplus over and above what the insurer expects to pay out for medical claims, expenses, taxes, and other obligations. All insurers must, by law, maintain minimum levels of surplus to ensure they will be able to meet their financial obligations to policyholders. Surplus includes common and preferred stock issued to its shareholders, any funds that are contributed to the insurer, and the accumulation of the insurer’s net income or losses since its inception. |
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|
axes and other adjustments —
|
Includes federal and
foreign income taxes, and income and expenses that are not included in the underwriting results or investment results. Generally these include net gain/(loss) from writeoff of agent/premium balances, restructuring costs, pension adjustments, and other extraordinary expenses not related to underwriting or investments. |
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|
Total revenue —
|
Net premium earned plus other
revenue. |
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T or F The threat of public hearings evidently encourages rate decreases in some states
|
T there is evidence that the simple ability
to hold a hearing is enough to give state regulators leverage to negotiate lower rates. |
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|
a thorough and rigorous rate review tends to lower rates T or f?
|
T States that conduct a thorough, rigorous review of the rate filing and the underlying
data and methodology report that they are often able to obtain significant reductions in rates from carriers. |
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In Colorado what % of rate increases sees a rigorous review by staff actuaries?
|
in an average year, only an
estimated 25% of rate filings receive a comprehensive review by a staff actuary. |
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Why is the existing system of employment based coverage as successful as it is in covering
workers and their families? |
Many employers, especially large ones, maintain that the answer lies in ERISA’s
pre-emption of state law. |
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Some primary features and benefits of erisa
|
ERISA provides a legal framework for the uniform provision of benefits by employers doing business
anywhere in the country. This uniformity allows multistate companies that self-insure to offer consistent benefit packages wherever they happen to be located, which results in ease of administration and lower expenses. |
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During the legislative enactment of Erisa, how was the monsanto case viewed?
|
The case was perceived by them as a prelude to a
revenue grab by Missouri so as to rationalize the imposition of a premium tax on employer contributions to noninsured employee benefit trusts. It was also perceived as having the collateral purpose of inducing such trusts to switch their operations to commercial insurers. |
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What does Erisa have to say about state regulation
|
ERISA not only sets national standards for employee benefit plans, but, most importantly, pre-empts all
state laws that “relate to” employee benefit plans (Sec. 514(a)). Within |
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|
How does Erisa treat state regulation of insurance
|
Within this broad pre-emption, however, the
act specifically preserves the states’ right to regulate the business of insurance under what is commonly called the “savings” clause (Sec. 514(b)(2)(A)). This clause effectively reinforces the states’ authority to regulate insurance under the McCarran-Ferguson Act (1945). |
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|
What is the three-prong test developed in Union Labor Life Ins. v. Pireno to determine whether an
activity or practice constituted the “business of insurance.” |
The activity in question must spread risk,
the relationship between insured and insurer must be an integral part of the activity, and it must be limited to entities in the traditional insurance industry (Union Labor Life Ins. Co. v. Pireno, 458 U.S. 119, 1982) |
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All plans, both insured and self-insured, benefit
from ERISA’s uniform what? |
1) regulations governing plan information, 2) fiduciary standards for persons responsible
for plan management, and 3) reporting and disclosure requirements. 4) ERISA pre-emption also provides consistent legal rights and remedies for participating employees and their dependents. |
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Prior to ERISA’s enactment, employee pension and health benefit plans were subject to preferential
federal tax treatment along with relatively weak disclosure requirements under what statute |
the Welfare and Pension Plan
Disclosure Act of 1958 (WPPDA). |
|
|
hat problems led to the enactment of ERISA
|
During the 1950s and 1960s, the lack of legal protections afforded pension plan participants resulted in
retirees in some well-publicized cases receiving much smaller retirement benefits (or in some cases no benefits) than what was promised. One of the most significant cases was the bankruptcy of the Studebaker automobile company in the early 1960s, which left thousands of long-tenured workers with only a fraction of their promised pension benefits. The Studebaker collapse led directly to the congressional hearings that culminated in the enactment of ERISA. |
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What does ERISA cover?
|
ERISA was drafted to cover all employee benefit plans, including health
benefits |
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|
during the ERISA conference, three dramatic instances of state action affecting
health and welfare plan development in a potentially injurious way were brought to the attention of the conferees - what were the three? |
…[t]he three problem areas (not necessarily listed in the order of
their importance) were (a) the Monsanto decision, (b) Hawaii’s prepaid Health Care Act and California’s threatened imitation of that model, and (c) pending state restrictions on prepaid legal services plans. |
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What problems did the Monsanto plan present?a Missouri lower court had held that the Monsanto company’s
noninsured health plan for its employees could not pay out benefits until it had satisfied the licensing requirements governing insurance companies in Missouri. |
1) Business and organized labor groups objected to the notion that a state could treat such a noninsured health plan trust fund as if it were an
insurance company subject to the regulation of commercial insurers under the supervision of the state’s insurance commissioner. 2) The case was perceived by them as a prelude to a revenue grab by Missouri so as to rationalize the imposition of a premium tax on employer contributions to noninsured employee benefit trusts. 3) It was also perceived as having the collateral purpose of inducing such trusts to switch their operations to commercial insurers. |
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ERISA established the federal government as the primary regulator of what?
|
private-sector employee benefit
plans. |
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|
Most of ERISA’s substantive provisions primarily address what
|
the private employment-based pension
system. |
|
|
ERISA mandates that a fiduciary’s duty is to act in the “sole interest” of plan participants and beneficiaries.
Specifically, a fiduciary must act with |
the “care, skill, prudence, and diligence” of a “prudent man”
|
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Can Fiduciaries be held personally liable for losses flowing from breach of fiduciary duty?
|
Fiduciaries are personally liable for any losses to a plan resulting from a breach of fiduciary duty
and can be barred from continuing in such capacity if the breach is grossly negligent. |
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|
ERISA not only sets national standards for employee benefit plans, but, most importantly, what?
|
pre-empts all
state laws that “relate to” employee benefit plans (Sec. 514(a)). |
|
|
What doe the Erisa savings clause do?
|
ERISA not only sets national standards for employee benefit plans, but, most importantly, pre-empts all
state laws that “relate to” employee benefit plans (Sec. 514(a)). Within this broad pre-emption, however, the act specifically preserves the states’ right to regulate the business of insurance under what is commonly called the “savings” clause (Sec. 514(b)(2)(A)). |
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|
What does ERISA's deemer clause control?
|
to protect self-insured plans from the
full reach of state regulation, ERISA includes another provision commonly called the “deemer” clause (Sec. 514(b)(2)(B)) that prevents states from deeming employee welfare benefit plans to be in the business of insurance. |
|
|
What may states regulate in health benefit plans offered by employers?
|
states may regulate certain
aspects of the insurance products sold to welfare benefit plans, but states have no ability to directly regulate self-insured arrangements. |
|
|
DC v. Washington Board of Trade—In District of Columbia v. Greater Washington Board of Trade
(506 U.S. 125, 1992), the Supreme Court addressed a workers’ compensation statute, and for guidance turned to the “having a connection with or referring to” language. The law in question would have required any employer that provided health insurance coverage to an employee to continue to provide the existing coverage or its equivalent after the employee had an injury causing a workers’ compensation claim. The Court Found? |
The Court found the District law was pre-empted under what many
observers considered a broad interpretation of the “relates to” language. |
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|
What was the key SCOTUS case that set the meaning of relates to?
|
Shaw v. Delta—In a key case, Shaw v. Delta Airlines, Inc. (463 U.S. 85, 1983), the Supreme Court
attempted to define the meaning of the words “relates to” or, in other words, which state laws were pre-empted by ERISA. The Court stated that “relates to” in Sec. 514 of ERISA means “having a connection with or referring to” an employee benefit plan, a sweeping albeit ambiguous standard. Furthermore, the Court noted that the clause was “conspicuous in its breadth.” |
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|
What SCOTUS case narrowed the breadth of prior relates to cases by holding hospital surcharges too tenuous to be preempted?
|
New York Blue Cross & Blue Shield v. Travelers—
|
|
|
While Travelers helped set some boundaries around the
scope of pre-emption, it did not provide a “bright-line” test as to when a state law will be considered “too tenuous, remote, or peripheral” or when it will be pre-empted. What did DeBuono v. NYSA-ILA Medical Services— hold? |
New York State gross receipts tax on medical
providers applied to a hospital owned and operated by a self-insured ERISA plan held that the tax was one of general applicability and did not affect ERISA’s objectives. |
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|
What type of state law escape ERISA preemption
|
a law of general applicability that imposes
burdens of administration on ERISA plans but is not the type of state law that Congress intended ERISA to supersede may survive ERISA pre-emption. |
|
|
What was the BOGGs v Boggs holding
|
claim in question was
determined to undermine a particular objective of ERISA so was preempted |
|
|
What three prong test must a state law pass to avoid ERISA preemption under the savings clause
|
The activity in question must spread risk,
the relationship between insured and insurer must be an integral part of the activity, and it must be limited to entities in the traditional insurance industry (Union Labor Life Ins. Co. v. Pireno, 458 U.S. 119, 1982). |
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|
Did SCOTUS take a broad or narrow view of ERISA deemer clause
|
the Court applied a broad interpretation of the deemer clause,
exempting self-insured ERISA plans from direct and indirect state regulation. |
|
|
the Court concluded that the civil enforcement
provisions of ERISA were intended to be ? |
the “exclusive vehicle for action by ERISA-plan
participants and beneficiaries asserting improper processing of a claim for benefits. |
|
|
IN Kentucky Associations v Miller the Supreme Court, which upheld the state law,
stating that it was making a “clean break” from the three-prong test. Under the Court’s holding, a state law is deemed to regulate insurance under Sec. 514(b) if it |
(1) is specifically directed toward
entities engaged in insurance and (2) substantially affects the risk pooling arrangement between the insured and the insurer. |
|
|
ERISA pre-emption has prevented individual states and localities from
? |
mandating
a minimum level of coverage for employment-based plans, and, so far, appears to prevent the states from mandating that employers provide health benefits. |
|
|
3 steps to reading a regulation
|
1) what statute is it part of - where does it fall within structure 2) What other regs does it link up with 3) what is the policy goal or intent of the agency
|
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|
how nay pages of regs from cms
|
200,000
|
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|
is medicare or medicaid a shared responsibility of the states and federal govt
|
medicaid
|
|
|
do terms of art carry same meaning across 4 systems of payment
|
no
|
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|
do terms of art carry same meaning across 4 systems of payment
|
no
|
|
|
Medicare pays for
|
items and services medically reasonable and necessary
Drugs are items! |
|
|
is Medicare a preventitive system
|
18.62 add on preventative care
no - items and services to treat illness and sickness |
|
|
how many preventative care services are paid by medicare
|
12-14
|
|
|
actors in healthcare payment system
|
patient, provider (providers, suppliers,practitioners) entity or actor who provides items and services, health plan or payor insurers etc
|
|
|
health plan pays on behalf of whom
|
patient
|
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|
promises made by provider to patient are transferred to ?
|
health plan - benefit or detriment
|
|
|
what system is the driving insurer with respect to coding and reimbursement
|
Medicare
|
|
|
what are the 4 primary healthcare payment systems in US?
|
1) erisa covering most private insurance or employee plans regulated by fed 2) state plans for individualsin open market 3) medicare 4) medicaid
|
|
|
what are the titles for medicare and medicaid
|
18 and 19
|
|
|
who uses the 1500 form
|
medicare practitioners fill it out to get reimbursed from cms
|
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|
what is 1450 form for
|
reimbursement for institutional payors - to capture charges
|
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|
what is a revcode on the 1450
|
institutional acts or items that do not have cpt codes
|
|
|
does everything that goes on a 1450 form have a revcode?
|
yes
|
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|
does illinois law devolve authority to regulate insurance to counties, cities etc.?
|
no state owns exclusive authority
|
