Hsm 546 W3 Dq2 Managedcare Under Writing

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HSM 546 W3 DQ2 ManagedCare Under Writing

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<b>Week 3: Payment Mechanisms - Discussion</b> <b>Managed-Care Underwriting (graded)</b><table width="100%" border="0" cellspacing="0" cellpadding="0"><tbody><tr><td>Discuss problems that MCOs have experienced when implementing capitation arrangements in specialty-care practices.</td></tr></tbody></table> <b>Responses</b>Responses are listed below in the following order: response, author and the date and time the response is posted.<table width="100%" border="0" cellspacing="0" cellpadding="0"><tbody><tr><td width="11"></td><td width="11"></td><td><b>Response </b></td><td width="160"><b>Author </b></td><td width="116"><b>Date/Time </b></td></tr></tbody></table> <table width="100%" border="0" cellspacing="0" cellpadding="0"><tbody><tr><td><table width="100%" border="0" cellspacing="0" cellpadding="0"><tbody><tr><td><table width="100%" border="0" cellspacing="0" cellpadding="0"><tbody><tr><td width="15"></td><td width="14"></td><td width="0"><b>Capitation </b></td><td nowrap="nowrap" width="200">Professor Johnson-Warren</td><td width="185">3/16/2013 8:45:48 PM</td></tr></tbody></table></td></tr><tr><td><table width="100%" border="0" cellspacing="0" cellpadding="0"><tbody><tr><td width="38"></td><td>Welcome to Week 3 (thread 2)Capitation eliminates the FFS incentives to overuse and brings the financial incentives of the capitated provider in line with the financial incentives of the HMO. The most common problem with capitation involves chance. When there are too few members in an enrolled base, a statistical chance of greater severity among the members exists. The problem of small numbers is especially acute in the early period of a PCP’s participation with the MCO. HMOs have offered to pay the PCP on a FFS basis for the first 6 months or until the PCP has more than 50 enrollees, whichever comes first. The pros and cons to capitation are further discussed in our readings this week.Let's get started on our second thread this week...Discuss problems that MCOs have experienced when implementing capitation arrangements in specialty-care practices. </td></tr></tbody></table></td></tr></tbody></table> <table width="100%" border="0" cellspacing="0" cellpadding="0"><tbody><tr><td><table width="100%" border="0" cellspacing="0" cellpadding="0"><tbody><tr><td width="70"></td><td width="14"></td><td width="0"><b>RE: Capitation </b></td><td nowrap="nowrap" width="200">Guertty Lopez</td><td width="185">3/16/2013 11:30:16 PM</td></tr></tbody></table></td></tr><tr><td><table width="100%" border="0" cellspacing="0" cellpadding="0"><tbody><tr><td width="93"></td><td>The textbook explains that capitation is prepayment for services on a per-member per-month (PMPM) basis. In other words, a physician is paid the same amount of money every month for a member regardless of whether that member receives services or not and regardless of how expensive those services are.It further explains that although many practices have now acclimated to capitation, there is a feeling that capitation is really funny money. When PCPs are receiving a capitation payment of $15, this is sometimes unconsciously (or consciously) confused with the office charge. In their minds, it appears as though everyone is coming in for service and demanding the most expensive care possible, all for an office charge of $15 It is easy to forget that many of the members who have signed up with that physician are not even coming in at all. It only takes 10% of the members to come in once per month to make it seem as if there is a never-ending stream of entitled demanders in the waiting room. The best approach to this is to make sure that the plan collects data on encounters so that the actual reimbursement per visit can be calculated.(Kongstvedt p. 97, 115-116)  </td></tr></tbody></table></td></tr></tbody></table> <table width="100%" border="0" cellspacing="0" cellpadding="0"><tbody><tr><td><table width="100%" border="0" cellspacing="0" cellpadding="0"><tbody><tr><td width="125"></td><td width="14"></td><td width="0"><b>RE: Capitation </b></td><td nowrap="nowrap" width="200">Sheriker Bellard</td><td width="185">3/20/2013 8:51:45 PM</td></tr></tbody></table></td></tr><tr><td><table width="100%" border="0" cellspacing="0" cellpadding="0"><tbody><tr><td width="148"></td><td>I have to agree with you Guertty. Providers oftent dont see the benefit of getting paid regardless if the patient come to the office or not but at the same time they must remember to realize this can be considered a little "LANGIAPPE". When patients do come in is to collect the appropriate information in order to be reimbursed. </td></tr></tbody></table></td></tr><tr><td><table width="100%" border="0" cellspacing="0" cellpadding="0"><tbody><tr><td width="125"></td><td width="14"></td><td width="0"><b>RE: Capitation </b></td><td nowrap="nowrap" width="200">Brenda Grant</td><td width="185">3/22/2013 4:57:55 PM</td></tr></tbody></table></td></tr><tr><td><table width="100%" border="0" cellspacing="0" cellpadding="0"><tbody><tr><td width="148"></td><td>Peer review is a good way to keep documentation of this. We utilized this in our clinic on the Navy side. There were two purposes to this. First, we had opened services to dependents as well as Active Duty. We were always excessively busy and wanted to ensure that our clinic was receiving correct compensation for the services which were being rendered. Secondly to ensure that the care which was being provided was appropriate for the needs of the patient. </td></tr></tbody></table></td></tr><tr><td><table width="100%" border="0" cellspacing="0" cellpadding="0"><tbody><tr><td width="70"></td><td width="14"></td><td width="0"><b>RE: Capitation </b></td><td nowrap="nowrap" width="200">Elena Hallars</td><td width="185">3/17/2013 6:26:19 AM</td></tr></tbody></table></td></tr><tr><td><table width="100%" border="0" cellspacing="0" cellpadding="0"><tbody><tr><td width="93"></td><td><i>Problems with capitation systemsThanks for the tip professor! Chance is the most common problem with capitation because when there are not enough members in a physician's base this cause too much finanical risk. The solution is to spread the risk for expensive procedures throug risk sharing.and use stop loss protection.In relation to MCOs this is an ACUTE problem and the way it is handled is through pursuading the providers to use FFS for a short time until they can get their member count up.Is capitation funny money?? Will patients come in and demand the most expensive care possible when the physician is recieving on $15. The best solution is make sure the plan collects data on encounters so that the actual reimbursments can be calculated.Inappropiate underutilization paying providers to not to do something. Is this a problem?According to our text the managed care systems provide better care than uncontrolled FFS systems. So manged care systems is better than uncontrolled FFS systems but still has problems.I like the way the chaper ends this section with, "IF primary care services undergo an reduction, the capitation payments will not go down, just as they will not go up when there is increases utilization." </i> </td></tr></tbody></table></td></tr></tbody></table> <table width="100%" border="0" cellspacing="0" cellpadding="0"><tbody><tr><td><table width="100%" border="0" cellspacing="0" cellpadding="0"><tbody><tr><td width="125"></td><td width="14"></td><td width="0"><b>RE: Capitation </b></td><td nowrap="nowrap" width="200">Sandy Williamson</td><td width="185">3/17/2013 4:51:52 PM</td></tr></tbody></table></td></tr><tr><td><table width="100%" border="0" cellspacing="0" cellpadding="0"><tbody><tr><td width="148"></td><td>If a specialist is to contract with an MCO, he or she must accept a number of somewhat unpalatable changes in the way the practice will be managed. These include most significantly, reductions in reimbursement levels, access to patients controlled through primary care gatekeepers, and increased administrative requirements necessary to perform effectively in a managed care environment.However, despite all these onerous changes, specialists must wake up and smell the coffee. Increased participation in managed care is critical to the success of their practice. Accepting a capitation to guarantee volume and ensure income will be a necessary part of a specialist's business plan in the 2000's.<a href="http://www.mcres.com/mcrmcc09.htm">http://www.mcres.com/mcrmcc09.htm</a>How would we know if this is how a doctor is running there office, can they have it both ways with different insurance companies? </td></tr></tbody></table></td></tr><tr><td><table width="100%" border="0" cellspacing="0" cellpadding="0"><tbody><tr><td width="70"></td><td width="14"></td><td width="0"><b>RE: Capitation </b></td><td nowrap="nowrap" width="200">Julie Gildemeister</td><td width="185">3/18/2013 4:22:47 AM</td></tr></tbody></table></td></tr><tr><td><table width="100%" border="0" cellspacing="0" cellpadding="0"><tbody><tr><td width="93"></td><td>Specialists assume much of the same risk of capitation as PCPs. However, because of their access to and utilization of more expensive services, the costs of providing services tend to be much higher for specialists than for PCPs.<i>When capitation brings down specialists' income, it's usually for the same reasons primary-care physicians have found: the rate is too low, the number of referrals has surpassed expectations, or the contract requires too many services. If specialist and primary-care services aren't clearly defined, primary-care physicians will tend to refer excessively. </i><a href="http://www.ifebp.org/pdf/harker/Capitation_Issues.pdf" target="_new">Capitation</a> (page 8)This can lead to a phenomenon called "specialist-dumping," where a few capitated specialists are overwhelmed with large numbers of MCO members. In such cases, they can rapidly blow through their capitation payments for the year (and even the withhold funds as well). This causes specialists to lose financially due to excessive risk. This also causes problems for the MCO due to patient dissatisfaction, increased claims denials, and negative impacts on provider/community relations. </td></tr></tbody></table></td></tr></tbody></table> <table width="100%" border="0" cellspacing="0" cellpadding="0"><tbody><tr><td><table width="100%" border="0" cellspacing="0" cellpadding="0"><tbody><tr><td width="125"></td><td width="14"></td><td width="0"><b>RE: Capitation </b></td><td nowrap="nowrap" width="200">Sherita Swinton</td><td width="185">3/18/2013 5:45:31 PM</td></tr></tbody></table></td></tr><tr><td><table width="100%" border="0" cellspacing="0" cellpadding="0"><tbody><tr><td width="148"></td><td>Capitation arrangements in specialty care practices, puts the specialists at a greater risk. Julie, you mentioned “specialist dumping;” and I found that very interesting. This is when the patients are fearful of the risk that can be manifested from an overutilization by the PCPs. These constraints lead to more financial costs.SheritaKongstvedt, P. (2007). Essentials of Managed Health Care (5th ed). Jones & Bartlett Publishers. Retrieved from <a href="http://devry.vitalsource.com/books/9780763797928">http://devry.vitalsource.com/books/9780763797928</a> </td></tr></tbody></table></td></tr></tbody></table> <table width="100%" border="0" cellspacing="0" cellpadding="0"><tbody><tr><td><table width="100%" border="0" cellspacing="0" cellpadding="0"><tbody><tr><td width="180"></td><td width="14"></td><td width="0"><b>RE: Capitation </b></td><td nowrap="nowrap" width="200">Julie Gildemeister</td><td width="185">3/20/2013 10:08:17 AM</td></tr></tbody></table></td></tr><tr><td><table width="100%" border="0" cellspacing="0" cellpadding="0"><tbody><tr><td width="203"></td><td>PCP's are often fearful of taking on complicated cases, even though the technicalities of the cases fall safely within the parameters of the PCP's expertise. In the reference I quoted, it states that many PCP's are not comfortable with the restrictions on utilization of specialists that can occur with capitation of the higher levels of care.As a veterinarian who provided primary care, I can think of several cases that challenged me. In the beginning, I was quicker to refer them to a specialist. However, I was fortunate in that I had access to specialists who were very willing to teach me about these cases, so that as I learned from them, I felt more comfortable referring to them less and less. For example, I referred all of my bloats to the surgeon until I started working at an emergency clinic. There one of the senior doctors mentored me through a couple of surgeries, therefore for the last seven years of practice I performed all of my bloat surgeries.Even if I'm practicing today, though, I still won't do back surgery. ;-) </td></tr></tbody></table></td></tr></tbody></table> <table width="100%" border="0" cellspacing="0" cellpadding="0"><tbody><tr><td><table width="100%" border="0" cellspacing="0" cellpadding="0"><tbody><tr><td width="235"></td><td width="14"></td><td width="0"><b>RE: Capitation </b></td><td nowrap="nowrap" width="200">Stephanie Lynch</td><td width="185">3/24/2013 6:07:06 PM</td></tr></tbody></table></td></tr><tr><td><table width="100%" border="0" cellspacing="0" cellpadding="0"><tbody><tr><td width="258"></td><td>I also think that many specialist want this kind of challenge and that's why they go into their area of expertise. </td></tr></tbody></table></td></tr><tr><td><table width="100%" border="0" cellspacing="0" cellpadding="0"><tbody><tr><td width="70"></td><td width="14"></td><td width="0"><b>RE: Capitation </b></td><td nowrap="nowrap" width="200">Letitia Armour</td><td width="185">3/18/2013 12:37:00 PM</td></tr></tbody></table></td></tr><tr><td><table width="100%" border="0" cellspacing="0" cellpadding="0"><tbody><tr><td width="93"></td><td>Professor Johnson-Warren,MCO agreed to fixed premium for the purpose of all medical care which provides for government, third party or commercial company. MCO must share the risk called capitation. MCO faced problem when implementing capitation when arranging specialty care practices. MCO designs specialty network which causes referral relationship more difficult to maintain. Also, many times based upon the pressure MCO place upon physician, through referrals and utilization management process by requiring higher level of managed care. Many physicians are not familiar with this process so they do not like it. I think it is a good idea to have some types of check and balance for physicians and hospital to make sure the patient is not over charged and follow strict medical practices and follow right standards.<a href="http://www.mcres.com/mcrmcc09.htm">http://www.mcres.com/mcrmcc09.htm</a> </td></tr></tbody></table></td></tr></tbody></table> <table width="100%" border="0" cellspacing="0" cellpadding="0"><tbody><tr><td><table width="100%" border="0" cellspacing="0" cellpadding="0"><tbody><tr><td width="70"></td><td width="14"></td><td width="0"><b>RE: Capitation </b></td><td nowrap="nowrap" width="200">David Judkins</td><td width="185">3/19/2013 1:22:20 PM</td></tr></tbody></table></td></tr><tr><td><table width="100%" border="0" cellspacing="0" cellpadding="0"><tbody><tr><td width="93"></td><td>Capitation is a set amount of money received or paid out. The text states the most common problem with capitation is chance. A physician group with 100 or fewer members may end up with members that have serious illnesses that are expensive to treat, such as AIDS or cancer. The risk for such expensive cases would need to be spread through common risk sharing pools. This could become very expensive. </td></tr></tbody></table></td></tr><tr><td><table width="100%" border="0" cellspacing="0" cellpadding="0"><tbody><tr><td width="70"></td><td width="14"></td><td width="0"><b>RE: Capitation </b></td><td nowrap="nowrap" width="200">Fredrick Casteel</td><td width="185">3/19/2013 2:08:57 PM</td></tr></tbody></table></td></tr><tr><td><table width="100%" border="0" cellspacing="0" cellpadding="0"><tbody><tr><td width="93"></td><td>The most common problems with capitation deals with chance due to a few members enrolled to make up for bad luck. Small numbers are common in the early stage, but a PCP’s will have to deal with a probationary period that will compose of a HMO unit the PCP is established. Another problem will be how the physicians and their office staff collect payment. The book states the best approach is to make sure that the plan collects data on encounters so that the actual reimbursement per visit can be calculated.Kongstvedt, P. (2007) Essentials of Managed Health Care 5^th edition, pp. 115-116 </td></tr></tbody></table></td></tr></tbody></table> <table width="100%" border="0" cellspacing="0" cellpadding="0"><tbody><tr><td><table width="100%" border="0" cellspacing="0" cellpadding="0"><tbody><tr><td width="125"></td><td width="14"></td><td width="0"><b>RE: Capitation </b></td><td nowrap="nowrap" width="200">Professor Johnson-Warren</td><td width="185">3/19/2013 8:23:55 PM</td></tr></tbody></table></td></tr><tr><td><table width="100%" border="0" cellspacing="0" cellpadding="0"><tbody><tr><td width="148"></td><td>Nice post Fredrick!"Payment is due at the time services are rendered." Collecting payment upfront important for daily ledgers in the medical office. Now this gives you a better point of view to why payment must be paid up front. </td></tr></tbody></table></td></tr></tbody></table> <table width="100%" border="0" cellspacing="0" cellpadding="0"><tbody><tr><td><table width="100%" border="0" cellspacing="0" cellpadding="0"><tbody><tr><td width="180"></td><td width="14"></td><td width="0"><b>RE: Capitation </b></td><td nowrap="nowrap" width="200">Tatiania Tabb</td><td width="185">3/21/2013 4:31:05 PM</td></tr></tbody></table></td></tr><tr><td><table width="100%" border="0" cellspacing="0" cellpadding="0"><tbody><tr><td width="203"></td><td>Yes Professor Johnson-Warren this is very much true and this made me remember a situation I had when I worked for an urgent care facility. At this urgent care facility we also offered drug screens for private patients. Private patients paid for there own services and it was mandatory to collect payment for the services that will be rendered to them prior to the services rendered. If I happened to forget a payment form a private patient; I would be responsible for replacing that payment myself. </td></tr></tbody></table></td></tr></tbody></table> <table width="100%" border="0" cellspacing="0" cellpadding="0"><tbody><tr><td><table width="100%" border="0" cellspacing="0" cellpadding="0"><tbody><tr><td width="235"></td><td width="14"></td><td width="0"><b>RE: Capitation </b></td><td nowrap="nowrap" width="200">Nikki Hetzer</td><td width="185">3/24/2013 9:20:57 PM</td></tr></tbody></table></td></tr><tr><td><table width="100%" border="0" cellspacing="0" cellpadding="0"><tbody><tr><td width="258"></td><td>Thanks for sharing that Tatiania. As I can see that with this sort of policy employees are probably less likely to forget to collect payments from private patients up front, it almost seems unfair to other professions, where mistakes by employees are covered by the company. I understand it is important for a medical office to collect payments up front for their financial health but I am sorry for the burden that was put on you. </td></tr></tbody></table></td></tr><tr><td><table width="100%" border="0" cellspacing="0" cellpadding="0"><tbody><tr><td width="180"></td><td width="14"></td><td width="0"><b>RE: Capitation </b></td><td nowrap="nowrap" width="200">Stephanie Lynch</td><td width="185">3/21/2013 5:45:22 PM</td></tr></tbody></table></td></tr><tr><td><table width="100%" border="0" cellspacing="0" cellpadding="0"><tbody><tr><td width="203"></td><td>I heard that doctors that The Mayo Clinic are all salary and that it doesn't matter how many or what test they order for their patients. Why wouldn't more facilities go to a plan like this. Wouldn't this be a better cost control for health care and cut done on unnecessary tests? </td></tr></tbody></table></td></tr></tbody></table> <table width="100%" border="0" cellspacing="0" cellpadding="0"><tbody><tr><td><table width="100%" border="0" cellspacing="0" cellpadding="0"><tbody><tr><td width="235"></td><td width="14"></td><td width="0"><b>RE: Capitation </b></td><td nowrap="nowrap" width="200">Professor Johnson-Warren</td><td width="185">3/22/2013 11:30:31 PM</td></tr></tbody></table></td></tr><tr><td><table width="100%" border="0" cellspacing="0" cellpadding="0"><tbody><tr><td width="258"></td><td>Thanks Stephanie for your comment.What works for Mayo Clinic may not work for every facility across the U.S. Unfortutnately, people believe the more test ordered does not ensure the best diagnosis. </td></tr></tbody></table></td></tr><tr><td><table width="100%" border="0" cellspacing="0" cellpadding="0"><tbody><tr><td width="180"></td><td width="14"></td><td width="0"><b>RE: Capitation </b></td><td nowrap="nowrap" width="200">Pedro Huertas</td><td width="185">3/21/2013 8:35:25 PM</td></tr></tbody></table></td></tr><tr><td><table width="100%" border="0" cellspacing="0" cellpadding="0"><tbody><tr><td width="203"></td><td>Collecting payment at the time services are rendered is extremely important for a medical facility to maintain its financial health. The failure of not collecting all or as much as possible before services are provided could result to significant losses. Collecting debt after the patient departs the facility could not only be difficult, but also costly. In fact, the healthcare debt recovery rate of 10.3 for hospitals and 17.8 for non-hospitals demonstrate the challenges of the collection process. Many medical facilities now offer financing options and even financial assistance programs to help cover the costs associated with caring for the uninsured. Here are some very interesting statistics to help visualize the impact of not collecting the same day:Health Care Collection Statistics: Facts and statistics about health care debt and collections<a href="http://www.acainternational.org/products-health-care-collection-statistics-5434.aspx">http://www.acainternational.org/products-health-care-collection-statistics-5434.aspx</a> </td></tr></tbody></table></td></tr></tbody></table> <table width="100%" border="0" cellspacing="0" cellpadding="0"><tbody><tr><td><table width="100%" border="0" cellspacing="0" cellpadding="0"><tbody><tr><td width="235"></td><td width="14"></td><td width="0"><b>RE: Capitation </b></td><td nowrap="nowrap" width="200">Sherita Swinton</td><td width="185">3/23/2013 7:25:07 PM</td></tr></tbody></table></td></tr><tr><td><table width="100%" border="0" cellspacing="0" cellpadding="0"><tbody><tr><td width="258"></td><td>Pedro,Very informative post! I agree that it is important to collect payment for medical care at the time of service. As opposed to receiving payment at a postponed date. I never really realized how significant the losses can be for medical facilities in failing to collect payments at the time service is provided. The website you provided was very informative and helpful. Thank you for sharing this information with us.Sherita </td></tr></tbody></table></td></tr></tbody></table> <table width="100%" border="0" cellspacing="0" cellpadding="0"><tbody><tr><td><table width="100%" border="0" cellspacing="0" cellpadding="0"><tbody><tr><td width="290"></td><td width="14"></td><td width="0"><b>RE: Capitation </b></td><td nowrap="nowrap" width="200">Stephanie Lynch</td><td width="185">3/24/2013 6:11:53 PM</td></tr></tbody></table></td></tr><tr><td><table width="100%" border="0" cellspacing="0" cellpadding="0"><tbody><tr><td width="313"></td><td>you would think that many facilities would do all that they could to get information about co-pays and such before patients come in. I know at the hospital I work at we do and will call patients when the information we have isn't correct. More and more doctor offices should do the same. </td></tr></tbody></table></td></tr></tbody></table> <table width="100%" border="0" cellspacing="0" cellpadding="0"><tbody><tr><td><table width="100%" border="0" cellspacing="0" cellpadding="0"><tbody><tr><td width="345"></td><td width="14"></td><td width="0"><b>RE: Capitation </b></td><td nowrap="nowrap" width="200">Pedro Huertas</td><td width="185">3/24/2013 8:08:24 PM</td></tr></tbody></table></td></tr><tr><td><table width="100%" border="0" cellspacing="0" cellpadding="0"><tbody><tr><td width="368"></td><td>Stephanie, you bring a good point regarding the duty of the facility to inform patients of potential out of pocket cost. As you stated, the medical facility needs to do as much as possible to collect the co-pays and other charges the same day of the visit. Patient education is important to achieve the desired results as many times most people do not even know or remember their share of the cost. We contact every patient scheduled at least 48 hours prior to the appointment to confirm the appointment and verify insurance coverage as well as to inform the patient about any co-pay for the visit. Takes us about 10 extra seconds to deliver such an important message, but we save a great deal of time, effort, and expenses by ensuring that the patient will be ready. In terms of efficiency, having to cancel appointments because patients are unable to pay prior to receiving services could have a negative impact on productivity and revenue. </td></tr></tbody></table></td></tr><tr><td><table width="100%" border="0" cellspacing="0" cellpadding="0"><tbody><tr><td width="70"></td><td width="14"></td><td width="0"><b>RE: Capitation </b></td><td nowrap="nowrap" width="200">Antonio Walker</td><td width="185">3/20/2013 5:17:29 AM</td></tr></tbody></table></td></tr><tr><td><table width="100%" border="0" cellspacing="0" cellpadding="0"><tbody><tr><td width="93"></td><td><b>Modified:</b>3/20/2013 5:27 AM</td></tr><tr><td width="93"></td><td>Mrs. Warren,A capitation system is the payment of healthcare providers in set amount for each person assigned to that provider or group, whether or not that person seeks care per period. The fee for service is payments made based on invoices for services provided. A capitation system provides certainty to both providers and payers, where as neither the healthcare provider nor the payer have any assurance to medical costs with the fee for services.“It is the specialists' fear that when they accept capitation, they are at risk for overutilization by the primary care physician. After all, it doesn't cost the PCP any more to send two or ten referrals to the specialist. The specialist will have to perform time-consuming utilization monitoring and education of the primary care physicians toward more appropriate referral patterns. By working with the primary care physicians to improve communication, successful relationships can be achieved (mcres.com, 1998).”Rosenberg, I. & Cameron, D. (1998) Managed Care Contracting: Specialty Capitation in a Managed Care Environment. Retrieved March 20, 2013 from <a href="http://www.mcres.com/mcrmcc09.htm">http://www.mcres.com/mcrmcc09.htm</a>The fear of overutilization seems to be a relevant concern today. </td></tr></tbody></table></td></tr></tbody></table> <table width="100%" border="0" cellspacing="0" cellpadding="0"><tbody><tr><td><table width="100%" border="0" cellspacing="0" cellpadding="0"><tbody><tr><td width="70"></td><td width="14"></td><td width="0"><b>RE: Capitation </b></td><td nowrap="nowrap" width="200">Jodie Knox</td><td width="185">3/21/2013 12:09:05 PM</td></tr></tbody></table></td></tr><tr><td><table width="100%" border="0" cellspacing="0" cellpadding="0"><tbody><tr><td width="93"></td><td>One of the biggest problems with capitation is the potential for overuse by some patients that cause a provider to lose money because the patient is over spending beyond their capitation rate to cover their anticipated costs. Those uncovered costs or over used services fall on the provider, at least to a point where their stop loss insurance kicks in. Some doctors may be incentivized to send their sickest patients elsewhere to control their costs. Additionally, doctors may only want to see a certain amount of capitation patients because they want to see a higher percentage of fee-for-service patients in order to maintain a profit.Jodie </td></tr></tbody></table></td></tr><tr><td><table width="100%" border="0" cellspacing="0" cellpadding="0"><tbody><tr><td width="70"></td><td width="14"></td><td width="0"><b>RE: Capitation </b></td><td nowrap="nowrap" width="200">Satchit Ladwa</td><td width="185">3/22/2013 11:07:26 PM</td></tr></tbody></table></td></tr><tr><td><table width="100%" border="0" cellspacing="0" cellpadding="0"><tbody><tr><td width="93"></td><td>Capitation problems that managed care faces...It is the specialists' fear that when they accept capitation, they are at risk for overutilization by the primary care physician. After all, it doesn't cost the PCP any more to send two or ten referrals to the specialist. The specialist will have to perform time-consuming utilization monitoring and education of the primary care physicians toward more appropriate referral patterns. By working with the primary care physicians to improve communication, successful relationships can be achieved.A specialist must clearly understand the full costs of his or her operation in order to monitor the capitation rate accepted. He or she must first determine what ultimate discount from fees is acceptable. A specialist can monitor the success of the cap rate by comparing the claims produced but not sent for collection, to the capitation check each month. Of course utilization will vary month to month, so it is important to compare the capitation payment to fee-for-service utilization over longer periods, such as quarterly, semi-annually, and annually. An investment in a system that can perform this function and provide tracking requirements for each MCO will be essential.Initially the provision of quality medical services under a capitation may seem excessively costly; and unfortunately there may appear to be incentive to cut costs by reducing services. Don't take this approach-it will invariably be most costly in the long run. Specialists may need to gain greater understanding of critical pathways in order to assume effective and efficient protocols for provision of care.<a href="http://www.mcres.com/mcrmcc09.htm">http://www.mcres.com/mcrmcc09.htm</a> </td></tr></tbody></table></td></tr><tr><td><table width="100%" border="0" cellspacing="0" cellpadding="0"><tbody><tr><td width="15"></td><td width="14"></td><td width="0"><b>MCO and Capitation </b></td><td nowrap="nowrap" width="200">Jorge Amador</td><td width="185">3/18/2013 12:58:33 PM</td></tr></tbody></table></td></tr><tr><td><table width="100%" border="0" cellspacing="0" cellpadding="0"><tbody><tr><td width="38"></td><td>Indeed when it comes to comparing the methods used and how they are utilized it is much harder for a specialty-care practice to meet the demands of a capitation system due to the specifics of that clinic being involved in. "As with PCP capitation, the services covered by the capitation payment must be clearly defined. It is not uncommon for certain procedures to be carved out of the capitation consideration. The reason for this is that those SCPs who perform high-cost procedures will be relatively disadvantaged compared to SCPs who perform only less expensive office-based care, even if both SCPs are in the same specialty". (Kongstvedt 109).With these issues it becomes hard for capitation to be the main norm for specialty-care practices due to these type of issues.When not being clear on the procedures it may not be covered yet may be needed so that leaves the practice not getting any assistance from the capitation arrangement. Procedures are more costly and more detailed as well as harder to comprehend when compared to the PCP reinbursement dealing with only basic typical procedures.Kongstvedt, Peter R.. ESSENTIALS MANAGED HEALTH CARE 5E VITALBOOKS, 5th Edition. Jones & Bartlett Publishers, 12/2007. </td></tr></tbody></table></td></tr></tbody></table> <table width="100%" border="0" cellspacing="0" cellpadding="0"><tbody><tr><td><table width="100%" border="0" cellspacing="0" cellpadding="0"><tbody><tr><td width="70"></td><td width="14"></td><td width="0"><b>RE: MCO and Capitation </b></td><td nowrap="nowrap" width="200">Elena Hallars</td><td width="185">3/19/2013 5:06:29 PM</td></tr></tbody></table></td></tr><tr><td><table width="100%" border="0" cellspacing="0" cellpadding="0"><tbody><tr><td width="93"></td><td><b>Modified:</b>3/20/2013 11:40 AM</td></tr><tr><td width="93"></td><td>Capitation research I thought I'd share with everyone.There are basically two kinds of capitation models: “Global Capitation” and “Partial" or "Blended Capitation”. Each can be applied in various scenarios.Under global capitation, whole networks of hospitals and physicians band together to receive single fixed monthly payments for enrolled health plan members. Payment is made on a per member basis. Generally, providers sign a single contract with a health plan to cover the care of groups of members, and then must determine a method of dividing up the capitated check among the provider group.Under a partial or blended capitation model, a single payment is made for a defined set of services, while other services involved in a patient’s care are paid for on a fee-for-service basis. Under each model of capitation, risk adjustment is essential to adequately compensate providers for the risk they take-on. Payments are differentiated based on the characteristics of the enrollees in each provider patient group. Common risk adjustment factors include age, sex, health status, and prior health care utilization, as well as socio-demographic factors such as residence, income, etc.Global Capitation: A global capitation model is applicable in a health maintenance organization (HMO) structure. The HMO is paid a specified amount per patient to deliver services over a set period of time. Usually the payment is determined on a per member/per month (PMPM) basis. The rates are generally calculated form projections of the services and costs of the provider’s patient population, based on historic costs. The payments vary to reflect the total number of patient for a provider and the demographic and acuity factors of the patient population. In some cases, co-payments may also be collected from embers for certain services. Under global capitation all care is covered under the fee including primary care, hospitalizations, specialist care and ancillary services.Partial or Blended Capitation: Under partial or blended capitation models, only certain types or categories of services are paid on a capitated basis. Typical scenarios under which partial capitation applies include primary care capitation where a capitation amount is paid to primary care practices for primary care services and in some cases, ancillary services provided under the direction of the primary care practice. Alternatively, specialists may be paid on a capitated basis for services they provide while the primary care services are paid fee-for-service. Other “carve-out” capitation arrangements may involve paying for certain care such as mental health on a capitation basis. This differs from episode-based payment in that all the services included to care for a patient by the mental health provider are covered.Partial capitation models are also being considered under accountable care organizations (ACOs) whereby the ACO would be at financial risk for some but not all of the items and services it provides. Section 3022 of the Patient Protection and Affordable Care Act created a new Medicare payment program to support Accountable Care Organizations. Section 10307 of the Act allows HHS and CMS to use payment models such as partial capitation to support ACOs.<a href="http://www.chqpr.org/downloads/PartialCapitationPaymentforACO.pdf">http://www.chqpr.org/downloads/PartialCapitationPaymentforACO.pdf</a> </td></tr></tbody></table></td></tr></tbody></table> <table width="100%" border="0" cellspacing="0" cellpadding="0"><tbody><tr><td><table width="100%" border="0" cellspacing="0" cellpadding="0"><tbody><tr><td width="125"></td><td width="14"></td><td width="0"><b>RE: MCO and Capitation </b></td><td nowrap="nowrap" width="200">Guertty Lopez</td><td width="185">3/19/2013 5:22:47 PM</td></tr></tbody></table></td></tr><tr><td><table width="100%" border="0" cellspacing="0" cellpadding="0"><tbody><tr><td width="148"></td><td>The link below states that out of the three capitation models that Elena mentioned above, the greatest political risk lies in global capitation because physicians are selected to participate and some will be disenfranchised. If the physicians have been participating in the IPA for a number of years, they may be locked out of patients that they have previously seen for some time. Some shareholders may be offended and it is the most politically risky undertaking.In the website it also mentions that In group capitation, prior authorization is eliminated, as physicians join together to develop guidelines and best practices. They can create guidelines in each specialty and across specialties. Group capitation can also provide meaningful data. Physicians know exactly how much is spent each year in each specialty and it can also measure utilization trends. It mentions that group capitation is an art, not a science. It needs to be constantly adjusted because the aim is not to reduce physician reimbursement, but to reduce unnecessary utilization.<a href="http://www.managedcaremag.com/archives/9708/9708.fieldrep_kullman.html">http://www.managedcaremag.com/archives/9708/9708.fieldrep_kullman.html</a> </td></tr></tbody></table></td></tr></tbody></table> <table width="100%" border="0" cellspacing="0" cellpadding="0"><tbody><tr><td><table width="100%" border="0" cellspacing="0" cellpadding="0"><tbody><tr><td width="180"></td><td width="14"></td><td width="0"><b>RE: MCO and Capitation </b></td><td nowrap="nowrap" width="200">Elena Hallars</td><td width="185">3/20/2013 11:33:56 AM</td></tr></tbody></table></td></tr><tr><td><table width="100%" border="0" cellspacing="0" cellpadding="0"><tbody><tr><td width="203"></td><td><b>Modified:</b>3/20/2013 11:37 AM</td></tr><tr><td width="203"></td><td><i>Global capitation is really risky but offers more opportunities and financial gain. The legal market and market conditions affect the decision to participate in global capitation.<b>1.State laws must allow providers to accept full risk.2.Health care premiums need to be at relatively high levels to justify the investment and effort required to take full risk.3. Health plans must be willing to capitate providers for full risk.4. Most successful full-risk contracts are in markets where hospitals compete aggressively for business.Physician skillsThis experience should consist of several years of accepting capitated payments for professional services and shared risk for hospital services.Utilization data will also help evaluate new health plans, determine how funds are distributed and evaluate how well new risk is managed.If a particular subgroup of providers has a negative attitude about managed care, this attitude will only worsen when greater degrees of risk are involved.set up a claim processing system to collect data<a href="http://www.acpinternist.org/archives/1998/04/globlcap.htm">http://www.acpinternist.org/archives/1998/04/globlcap.htm</a>To be successful, highly capitated organizations need to manage care. Prospective medical management includes preauthorization for nonemergency specialty referrals, procedures and hospital admissions.</b></i> </td></tr></tbody></table></td></tr><tr><td><table width="100%" border="0" cellspacing="0" cellpadding="0"><tbody><tr><td width="70"></td><td width="14"></td><td width="0"><b>RE: MCO and Capitation </b></td><td nowrap="nowrap" width="200">Jodie Knox</td><td width="185">3/22/2013 2:36:36 PM</td></tr></tbody></table></td></tr><tr><td><table width="100%" border="0" cellspacing="0" cellpadding="0"><tbody><tr><td width="93"></td><td>I did read the same thing, that some specialists use capitation but not the majority. I can imagine it would be possible though. With a specialist, they have certain procedures, practices, diagnostics and tests that they run within their line of specialty care. I would imagine that the capitation rates would be adjusted for these known procedure costs and there would be a way to make it work as well as it would with primary care providers in sense of predicting costs. I see the problem of being large numbers. Capitation is more effective when you have a large number of patients which is normal for primary care providers where specialists may not be able to rely on these types of patient numbers (unless they are an OB-Gyn)Jodie </td></tr></tbody></table></td></tr></tbody></table> <table width="100%" border="0" cellspacing="0" cellpadding="0"><tbody><tr><td><table width="100%" border="0" cellspacing="0" cellpadding="0"><tbody><tr><td width="125"></td><td width="14"></td><td width="0"><b>RE: MCO and Capitation </b></td><td nowrap="nowrap" width="200">Latia Phelps</td><td width="185">3/24/2013 8:10:13 PM</td></tr></tbody></table></td></tr><tr><td><table width="100%" border="0" cellspacing="0" cellpadding="0"><tbody><tr><td width="148"></td><td>I agree with you Jodie, capitation can be beneficial for physicians with a large patient pool. Since the patient and the physician are aware of the services and have a set list. The charges that are incurred are easy to manage and both the patient and the doctor relationship will be as well. </td></tr></tbody></table></td></tr><tr><td><table width="100%" border="0" cellspacing="0" cellpadding="0"><tbody><tr><td width="15"></td><td width="14"></td><td width="0"><b>Capitation </b></td><td nowrap="nowrap" width="200">Lisa Kieffer</td><td width="185">3/19/2013 7:10:31 PM</td></tr></tbody></table></td></tr><tr><td><table width="100%" border="0" cellspacing="0" cellpadding="0"><tbody><tr><td width="38"></td><td>This site Managed Care Resources, Inc. is a great site to find out more about Managed Care. Professor have you been to this site yet? It's very informative and seems to be up-to-date with its information. Below is from the site:Physicians have increased professional risk. The ordering of diagnostic tests and additional referrals "just to be sure", is scrutinized by the MCOs through their referral and utilization management processes. In many ways the physician is held to higher standards in servicing a patient, standards with which many of them do not agree, and are not accustomed to meeting. Additionally, clinical pathways by disease, stipulating what some refer to as "recipes" for services, are now being widely recognized and utilized, requiring the specialist to provide medical service in accordance to the MCO's clinical pathways, and not necessarily to his or her professional judgement alone.A specialist must clearly understand the full costs of his or her operation in order to monitor the capitation rate accepted. He or she must first determine what ultimate discount from fees is acceptable. A specialist can monitor the success of the cap rate by comparing the claims produced but not sent for collection, to the capitation check each month. Of course utilization will vary month to month, so it is important to compare the capitation payment to fee-for-service utilization over longer periods, such as quarterly, semi-annually, and annually. An investment in a system that can perform this function and provide tracking requirements for each MCO will be essential.<a href="http://www.mcres.com/mcrmcc09.htm">http://www.mcres.com/mcrmcc09.htm</a> </td></tr></tbody></table></td></tr></tbody></table> <table width="100%" border="0" cellspacing="0" cellpadding="0"><tbody><tr><td><table width="100%" border="0" cellspacing="0" cellpadding="0"><tbody><tr><td width="70"></td><td width="14"></td><td width="0"><b>RE: Capitation </b></td><td nowrap="nowrap" width="200">Jodie Knox</td><td width="185">3/23/2013 9:08:58 AM</td></tr></tbody></table></td></tr><tr><td><table width="100%" border="0" cellspacing="0" cellpadding="0"><tbody><tr><td width="93"></td><td>Overall, thinking about capitation and fee-for-service, it makes me think that the doctor is put in a bad place to make good decisions on the whole for the patient, the insurance company, or themselves. Making decisions that are best for one of these three will be worse for the other. Personally, I would prefer a doctor who is salaried so that they are comfortable financially after all of their hard work to become a doctor but that they don't have any financial incentives in the administering of care. I feel that a salaried doctor would make a decision that is best for the patient and follows their medical institution's practice because there are no financial incentives involved....it seems like this would make it easier to just do their job. Leave the insurance negotiations to the hospital or medical institution and let the doctor's conscience be free of the financial decisions. I know this sounds a bit idealistic but if I were choosing a doctor, it would make me feel good to know that no matter what they do for me, they are making the same amount of money and not at risk for losing financially to order necessary tests.Jodie </td></tr></tbody></table></td></tr></tbody></table> <table width="100%" border="0" cellspacing="0" cellpadding="0"><tbody><tr><td><table width="100%" border="0" cellspacing="0" cellpadding="0"><tbody><tr><td width="125"></td><td width="14"></td><td width="0"><b>RE: Capitation </b></td><td nowrap="nowrap" width="200">Stephanie Lynch</td><td width="185">3/24/2013 6:13:29 PM</td></tr></tbody></table></td></tr><tr><td><table width="100%" border="0" cellspacing="0" cellpadding="0"><tbody><tr><td width="148"></td><td>I feel the same way. Jodie. I know that doctors at the Mayo Clinic are salaried. </td></tr></tbody></table></td></tr><tr><td><table width="100%" border="0" cellspacing="0" cellpadding="0"><tbody><tr><td width="15"></td><td width="14"></td><td width="0"><b>Capitation Is for Specialists, Not for Primary Care Physicians </b></td><td nowrap="nowrap" width="200">Jose Valderama-Sierra</td><td width="185">3/19/2013 7:13:43 PM</td></tr></tbody></table></td></tr><tr><td><table width="100%" border="0" cellspacing="0" cellpadding="0"><tbody><tr><td width="38"></td><td>That decision made, the MSO sent a Request for Proposal (RFP) to current IPA providers only, in specialties where there are large volumes of patients. Considerable time was spent developing the RFP, which included review by various IPA committees and legal review. The RFP consisted of several sections:1. Geography — How do you plan to cover our large geographic area and participation with three hospitals? The aim was to have one group, not three or four, cover three hospitals and the whole geographic area.2 . Comprehensive services — Can you provide all of the services in your specialty? For example, when the RFP was sent to oncologists, it was important to know that they could provide chemotherapy services including drugs. The goal was to cover as many services as possible under capitation.3. Accessibility — Did you have offices in the appropriate areas? Have you passed an office audit? What are your appointment times? Can you cover privileges at three hospitals? There were many categories within this topic.4. Quality — Unified requested patient satisfaction surveys and credentialing information for physicians and office staff (even though they were already credentialed through the IPA). HMOs were contacted for their satisfaction surveys and utilization data. Assessing the quality of care without sufficient data is difficult, but we did the best we could with the measurements available.5. Cost of Care — Per-member-per-month bids were requested. Although cost of care was very important, selection was not made according to the lowest bidder.The RFP stimulated individual physicians and small group practices to join together to respond to the needs of the IPA. There was no way that solo physicians could answer the RFP without getting together with their peers, and that is exactly what happened. Specialists made their own selection as to who was in the group. The IPA did not participate in the selection of these physicians. Who was in and who was out was determined by the group.In some cases, several groups answered the RFP. The IPA was then faced with making difficult choices. After several committees reviewed the proposals, the ultimate decision was made by a new primary care committee for the purpose of this selection process. Its decision was then approved by the United Physicians board. </td></tr></tbody></table></td></tr></tbody></table> <table width="100%" border="0" cellspacing="0" cellpadding="0"><tbody><tr><td><table width="100%" border="0" cellspacing="0" cellpadding="0"><tbody><tr><td width="15"></td><td width="14"></td><td width="0"><b>Managed-Care Underwriting </b></td><td nowrap="nowrap" width="200">Tatiania Tabb</td><td width="185">3/19/2013 7:31:20 PM</td></tr></tbody></table></td></tr><tr><td><table width="100%" border="0" cellspacing="0" cellpadding="0"><tbody><tr><td width="38"></td><td>MCO also known as Managed Care Organizations have faced money rate problems when dealing with capitation arrangements in specialty-care practice. It is stated that "however, relying too naively on data from existing MCOs can result in a feedback loop, as, for example, MCO provider payment rates are used to determine MCO capitation rates, which in turn affect provider payment rates" (<a href="http://www.forbes.com/sites/aroy/2012/10/18/benefits-and-challenges-of-medicaid-managed-care/">http://www.forbes.com/sites/aroy/2012/10/18/benefits-and-challenges-of-medicaid-managed-care/</a>). It is important to remember that capitation and MCO do not only effect rates involved but it also affects physicians salaries. To make sure that capitation is correct and current it is important to make sure that "states to use the best and most relevant actuarial data available when calculating capitation rates" (<a href="http://www.forbes.com/sites/aroy/2012/10/18/benefits-and-challenges-of-medicaid-managed-care/">http://www.forbes.com/sites/aroy/2012/10/18/benefits-and-challenges-of-medicaid-managed-care/</a>).Sources:<a href="http://www.forbes.com/sites/aroy/2012/10/18/benefits-and-challenges-of-medicaid-managed-care/">http://www.forbes.com/sites/aroy/2012/10/18/benefits-and-challenges-of-medicaid-managed-care/</a> </td></tr></tbody></table></td></tr><tr><td><table width="100%" border="0" cellspacing="0" cellpadding="0"><tbody><tr><td width="15"></td><td width="14"></td><td width="0"><b>RE: COST of an Insurance Policy </b></td><td nowrap="nowrap" width="200">Professor Johnson-Warren</td><td width="185">3/19/2013 8:20:44 PM</td></tr></tbody></table></td></tr><tr><td><table width="100%" border="0" cellspacing="0" cellpadding="0"><tbody><tr><td width="38"></td><td><b>Modified:</b>3/19/2013 8:25 PM</td></tr><tr><td width="38"></td><td><p align="center"><b>Underwriters use what four items when determining the cost of a policy?</b><b></b></p> </td></tr></tbody></table></td></tr></tbody></table> <table width="100%" border="0" cellspacing="0" cellpadding="0"><tbody><tr><td><table width="100%" border="0" cellspacing="0" cellpadding="0"><tbody><tr><td width="70"></td><td width="14"></td><td width="0"><b>RE: COST of an Insurance Policy </b></td><td nowrap="nowrap" width="200">Peru Tuika-Soske</td><td width="185">3/19/2013 11:05:39 PM</td></tr></tbody></table></td></tr><tr><td><table width="100%" border="0" cellspacing="0" cellpadding="0"><tbody><tr><td width="93"></td><td>In determining the cost of policy, underwriters use the following four items; health status, ability to pay the premium, availability of other coverage, and historical persistency.These all factor in how much a cost of insurance policy they are going to charge for the person. They want to make sure that there are no preexisting conditions for the person they are going to insure, they are able to make the payments for the type of coverage they have, they have to see if the individual or group change policies frequently, because they want committed people who will not switch after a couple months or one year. </td></tr></tbody></table></td></tr></tbody></table> <table width="100%" border="0" cellspacing="0" cellpadding="0"><tbody><tr><td><table width="100%" border="0" cellspacing="0" cellpadding="0"><tbody><tr><td width="125"></td><td width="14"></td><td width="0"><b>RE: COST of an Insurance Policy </b></td><td nowrap="nowrap" width="200">Laura Wimberly</td><td width="185">3/20/2013 6:55:09 PM</td></tr></tbody></table></td></tr><tr><td><table width="100%" border="0" cellspacing="0" cellpadding="0"><tbody><tr><td width="148"></td><td>The purpose of utilizing these items (health status, ability to pay premium, availability of other coverage and historical persistency) is to prevent people from only purchasing insurance when they're sick or have some need for medical care (adverse selection). If these criteria(s) were not in place individuals will not utilize insurance until there is a critical need disregarding any pre-existing medical conditions. Once people wait to purchase insurance at the last minute would increase the premiums in which insurance companies charge in order for them to pay the claims. </td></tr></tbody></table></td></tr><tr><td><table width="100%" border="0" cellspacing="0" cellpadding="0"><tbody><tr><td width="125"></td><td width="14"></td><td width="0"><b>RE: COST of an Insurance Policy </b></td><td nowrap="nowrap" width="200">Pedro Huertas</td><td width="185">3/20/2013 8:54:49 PM</td></tr></tbody></table></td></tr><tr><td><table width="100%" border="0" cellspacing="0" cellpadding="0"><tbody><tr><td width="148"></td><td>Peru and all, medical underwriting plays an important role in today’s healthcare, but that role is about to change. The Patient Protection and Affordable Care Act include several prohibitions that will impact underwriting decisions. The ACT prohibits insurers from basing decisions using some of the key factors you mentioned in your post. Factors such as health status, mental or physical, medical conditions, claims experience, medical history, genetic information, disability, and others are included in the limitations. The ban on medical underwriting will have a significant impact on the way insurance costs are determine.<a href="http://democrats.senate.gov/pdfs/reform/patient-protection-affordable-care-act.pdf">http://democrats.senate.gov/pdfs/reform/patient-protection-affordable-care-act.pdf</a> </td></tr></tbody></table></td></tr></tbody></table> <table width="100%" border="0" cellspacing="0" cellpadding="0"><tbody><tr><td><table width="100%" border="0" cellspacing="0" cellpadding="0"><tbody><tr><td width="180"></td><td width="14"></td><td width="0"><b>RE: COST of an Insurance Policy </b></td><td nowrap="nowrap" width="200">Professor Johnson-Warren</td><td width="185">3/20/2013 11:28:57 PM</td></tr></tbody></table></td></tr><tr><td><table width="100%" border="0" cellspacing="0" cellpadding="0"><tbody><tr><td width="203"></td><td>Thanks Pedro for bringing PPACA to the forefront of the discussion. The world as we know it will change and has had several points of change in the last two years. For instance, the age a child can stay on their parent's insurance is up to age 26. The extension of coverage will cover the gap found with college students and young adults. Health insurance and healthcare will embrace many of the changes ahead. </td></tr></tbody></table></td></tr></tbody></table> <table width="100%" border="0" cellspacing="0" cellpadding="0"><tbody><tr><td><table width="100%" border="0" cellspacing="0" cellpadding="0"><tbody><tr><td width="235"></td><td width="14"></td><td width="0"><b>RE: COST of an Insurance Policy </b></td><td nowrap="nowrap" width="200">Peru Tuika-Soske</td><td width="185">3/21/2013 5:35:28 PM</td></tr></tbody></table></td></tr><tr><td><table width="100%" border="0" cellspacing="0" cellpadding="0"><tbody><tr><td width="258"></td><td>I agree. Thanks Pedro for bringing that up. I welcome the many changes ahead and only wish that it was put into place sooner. My father had many pre-existing conditions which disqualified him for health care insurance. He tried many times to get insurance but was always turned away because of his pre-existing conditions. He passed away in 2009 without it and you know how that story went.I believe the PPACA is great for all Americans who have been limited and turned away for health insurance in the past. And as you have mentioned professor, for those who are 26 and under who will be able to stay on their parents insurance coverage is good as well because out of six children, four of my siblings are still able to be covered. </td></tr></tbody></table></td></tr></tbody></table> <table width="100%" border="0" cellspacing="0" cellpadding="0"><tbody><tr><td><table width="100%" border="0" cellspacing="0" cellpadding="0"><tbody><tr><td width="290"></td><td width="14"></td><td width="0"><b>RE: COST of an Insurance Policy </b></td><td nowrap="nowrap" width="200">Keniyotha Williams</td><td width="185">3/21/2013 10:24:40 PM</td></tr></tbody></table></td></tr><tr><td><table width="100%" border="0" cellspacing="0" cellpadding="0"><tbody><tr><td width="313"></td><td>Peru, I am so sorry to hear about your father. I guess that's why Obama pushed for care for citizens who had pre-existing conditions. His mother died of cancer and she was unable to receive care for her pre-existing condition. At first, it was illegal to deny coverage to children under 19 because of pre-existing conditions. Starting in 2014, insurance companies will no longer be able to deny coverage to any person with pre-existing condition. The best part is that there are laws to prevent insurance companies from hiking up the price significantly because of pre-existing conditions. I'm so certain that the new law will assist the self-employed citizens. There are approximately 22 million self-employed individuals. Of the 22 million, 1/3 of them are uninsured. The new law would help the many who were denied insurance and suffering.Mike BlountHealth Insurance Market Reforms<i>San Diego Business Journal</i>Volume 34 issue 1 p.41/7/2013 </td></tr></tbody></table></td></tr><tr><td><table width="100%" border="0" cellspacing="0" cellpadding="0"><tbody><tr><td width="290"></td><td width="14"></td><td width="0"><b>RE: COST of an Insurance Policy </b></td><td nowrap="nowrap" width="200">Julie Hicks</td><td width="185">3/21/2013 10:27:15 PM</td></tr></tbody></table></td></tr><tr><td><table width="100%" border="0" cellspacing="0" cellpadding="0"><tbody><tr><td width="313"></td><td>I agree, it give the young person time to possibly find stable employment with benefits of course or continue there education in n advanced degree. I am sure my son will be grateful for the extension since this will affect us with determining his medical benefits under me. I believe these changes will be beneficial to me as well in the future as I age. </td></tr></tbody></table></td></tr><tr><td><table width="100%" border="0" cellspacing="0" cellpadding="0"><tbody><tr><td width="235"></td><td width="14"></td><td width="0"><b>RE: COST of an Insurance Policy </b></td><td nowrap="nowrap" width="200">Jorge Amador</td><td width="185">3/22/2013 11:36:21 AM</td></tr></tbody></table></td></tr><tr><td><table width="100%" border="0" cellspacing="0" cellpadding="0"><tbody><tr><td width="258"></td><td>Professor,Indeed the changes in healthcare are coming and will keep on changing as we get ready for the Healthcare requirements starting in 2014 where everyone has to have some type of healthcare. This has been fought for years about having everyone forced to have some type of coverage, yet it will be interesting the enforcement that will take place to implement these rules. The first solution which is making everyone have healthcare of their own will help with some of the costs associated with government medical programs so that way it will help more people become covered and make sure to become a healthier country. The challenge will come in how providers give the healthcare and improving the ability of PCP to give the proper care the first time around. </td></tr></tbody></table></td></tr></tbody></table> <table width="100%" border="0" cellspacing="0" cellpadding="0"><tbody><tr><td><table width="100%" border="0" cellspacing="0" cellpadding="0"><tbody><tr><td width="290"></td><td width="14"></td><td width="0"><b>RE: COST of an Insurance Policy </b></td><td nowrap="nowrap" width="200">Teresa O'Brien</td><td width="185">3/24/2013 8:42:34 PM</td></tr></tbody></table></td></tr><tr><td><table width="100%" border="0" cellspacing="0" cellpadding="0"><tbody><tr><td width="313"></td><td>According to PPACA.com, another benefit of the PPACA beginning in 2014 is an increase in lifetime and Annual Limits. Group health plans and health insurance issuers offering group or individual health insurance coverage may not impose lifetime limits or unreasonable annual limits on the dollar value of essential health benefits. This condition applies to all plans, although plans were allowed to request a waiver of the annual limit requirement through HHS. The annual limit waiver program closed to applications effective Sept. 22, 2011. All annual limits will also be prohibited beginning in 2014. (retrieved from <a href="http://ppaca.com/">http://ppaca.com/</a> )This does not help many people facing theses constraints now, but something to look forward to for us and our children's generations to come. Hoping the long term goal is realized and understand change is sometimes slow and often painful. </td></tr></tbody></table></td></tr><tr><td><table width="100%" border="0" cellspacing="0" cellpadding="0"><tbody><tr><td width="235"></td><td width="14"></td><td width="0"><b>RE: COST of an Insurance Policy </b></td><td nowrap="nowrap" width="200">Stephanie Lynch</td><td width="185">3/24/2013 6:17:18 PM</td></tr></tbody></table></td></tr><tr><td><table width="100%" border="0" cellspacing="0" cellpadding="0"><tbody><tr><td width="258"></td><td>I think this is a great start to reform. I admit that it's not perfect, but it's a start. Those that want to repeal it out right make no sense to me. I say give it a chance and make changes to make it better. </td></tr></tbody></table></td></tr></tbody></table> <table width="100%" border="0" cellspacing="0" cellpadding="0"><tbody><tr><td><table width="100%" border="0" cellspacing="0" cellpadding="0"><tbody><tr><td width="290"></td><td width="14"></td><td width="0"><b>RE: COST of an Insurance Policy </b></td><td nowrap="nowrap" width="200">Teresa O'Brien</td><td width="185">3/24/2013 8:52:57 PM</td></tr></tbody></table></td></tr><tr><td><table width="100%" border="0" cellspacing="0" cellpadding="0"><tbody><tr><td width="313"></td><td>I think people get impatient and do not realize just how long a change of this magnitude will take, and how long it takes to make any changes in the future to come. There are so many regulations that come down through the pipeline as it is today as a matter of standard process, and companies have been preparing for these new Obama care initiatives, along with other key initiatives like ICD-10 implementations (deadline by Oct 14). ICD-10 represents the 10th revision of the <i>International Statistical Classification of Diseases and Related Health Problems (ICD)</i>, a medical classification list for coding for diseases, signs and symptoms, abnormal findings, complaints, social circumstances, and external causes of injury or diseases. (Wiki) These large initiatives take sometimes years to implement, and then a few more years until goals are realized. </td></tr></tbody></table></td></tr><tr><td><table width="100%" border="0" cellspacing="0" cellpadding="0"><tbody><tr><td width="290"></td><td width="14"></td><td width="0"><b>RE: COST of an Insurance Policy </b></td><td nowrap="nowrap" width="200">Professor Johnson-Warren</td><td width="185">3/24/2013 10:08:07 PM</td></tr></tbody></table></td></tr><tr><td><table width="100%" border="0" cellspacing="0" cellpadding="0"><tbody><tr><td width="313"></td><td>Thanks Stephanie for your post...Health Reform is not perfect and many people have questions to how it will be implemented. Many worry about how it will be funded? However, it was the same question in 1965 with Medicare and Medicaid. Sometimes we have to just try for the well being of American Citizens. </td></tr></tbody></table></td></tr><tr><td><table width="100%" border="0" cellspacing="0" cellpadding="0"><tbody><tr><td width="125"></td><td width="14"></td><td width="0"><b>RE: COST of an Insurance Policy </b></td><td nowrap="nowrap" width="200">Sheriker Bellard</td><td width="185">3/21/2013 8:59:24 PM</td></tr></tbody></table></td></tr><tr><td><table width="100%" border="0" cellspacing="0" cellpadding="0"><tbody><tr><td width="148"></td><td>Peru I often see insurance companies giving customers ( the patient) a credit rating based upon their insurance rating. Of course I can understand that there are some really sick patients such as individuals with ESRD or longterm illness and their visits cost a lot to maintain due to the severity of their condition, of course its going to cost more for the patient. Also there are the patients that always tend to have a lapse in coverage as this can create a problem with securing insurance in the event the patient does develope prex conditons when there is a gap. I can also understand when a patient gets frustrated behind the price of their premium but at the same time this should be explained to them as well. </td></tr></tbody></table></td></tr></tbody></table> <table width="100%" border="0" cellspacing="0" cellpadding="0"><tbody><tr><td><table width="100%" border="0" cellspacing="0" cellpadding="0"><tbody><tr><td width="125"></td><td width="14"></td><td width="0"><b>RE: COST of an Insurance Policy </b></td><td nowrap="nowrap" width="200">Satchit Ladwa</td><td width="185">3/24/2013 12:18:59 AM</td></tr></tbody></table></td></tr><tr><td><table width="100%" border="0" cellspacing="0" cellpadding="0"><tbody><tr><td width="148"></td><td>The different types of fee-for-service include indemnity plans and reimbursement plans. In an indemnity plan, the insurer sets an amount that it will pay for a specific medical service. In a reimbursement plan, the patient must pay all fees up front and then file claims to be reimbursed by the insurer. Fee-for-service health care is no longer widely in use. Most people today have some kind of managed care insurance.http://www.faqs.org/health/Healthy-Living-V2/Health-Care-Systems-Managed-health-care-vs-fee-for-service.html </td></tr></tbody></table></td></tr><tr><td><table width="100%" border="0" cellspacing="0" cellpadding="0"><tbody><tr><td width="70"></td><td width="14"></td><td width="0"><b>RE: COST of an Insurance Policy </b></td><td nowrap="nowrap" width="200">Julie Hicks</td><td width="185">3/19/2013 11:07:22 PM</td></tr></tbody></table></td></tr><tr><td><table width="100%" border="0" cellspacing="0" cellpadding="0"><tbody><tr><td width="93"></td><td>Underwriters use the following to determine the policy: "Health status, ability to pay the premium, availability of other coverage, and historical persistence."Health status, the doctors notes of the patients physical condition, types of medication taken, medical survey, injuries listed on job, cost, etc. This information will tell the insurance carrier or not whether this person is good health condition to follow through with a policy.The is stage can determine if certain medical limits may be reached.Ability to pay is determine by credit status or salary. This help s ensure that payments will be made.Other coverage so, they can try to come close to what coverage have or need to match.Persistency tells the insurer that the company they are dealing with is stable.. </td></tr></tbody></table></td></tr></tbody></table> <table width="100%" border="0" cellspacing="0" cellpadding="0"><tbody><tr><td><table width="100%" border="0" cellspacing="0" cellpadding="0"><tbody><tr><td width="70"></td><td width="14"></td><td width="0"><b>RE: COST of an Insurance Policy </b></td><td nowrap="nowrap" width="200">Jose Valderama-Sierra</td><td width="185">3/20/2013 8:36:47 AM</td></tr></tbody></table></td></tr><tr><td><table width="100%" border="0" cellspacing="0" cellpadding="0"><tbody><tr><td width="93"></td><td>Underwriting Guidelines are a set of rules that an insurer follows in classifying and assessing the class of risk associated with an applicant, and can vary from each insurer according to the amount of risk the insurer can assume. Each applicant is ‘rated’ according to sex, age, height, weight, medical conditions, medical history, smoking status, occupation, and even hobbies (riding motorcycles, rock climbing, etc). The policy’s risk classification and associated premium rate (monthly cost) are determined using this rating system.Risk selection is the method in which underwriters use to establish whether an applicant is insurable and to what level of risk might they pose to the insurer.Insurance premiums are adjusted based upon the applicant’s level of risk, whether it be preferred, standard or substandard. Most insurance companies provide a 10% discount to applicants who qualify for a ‘preferred’ risk status. At the same time, active tobacco users and applicants with certain medical conditions are often rated as ‘substandard,’ and often charged additional premium to help balance the associated risk to the insurance company.  </td></tr></tbody></table></td></tr></tbody></table> <table width="100%" border="0" cellspacing="0" cellpadding="0"><tbody><tr><td><table width="100%" border="0" cellspacing="0" cellpadding="0"><tbody><tr><td width="125"></td><td width="14"></td><td width="0"><b>RE: COST of an Insurance Policy </b></td><td nowrap="nowrap" width="200">Julie Gildemeister</td><td width="185">3/20/2013 10:32:36 AM</td></tr></tbody></table></td></tr><tr><td><table width="100%" border="0" cellspacing="0" cellpadding="0"><tbody><tr><td width="148"></td><td>It seems to me that insurance underwriters use tobacco use as a primary risk factor.When I was hired at my current job and offered the employer's policy, one of the questions I was asked was "Do I use tobacco, now or in the past?" I was glad to be able to answer "no," as I knew those who used tobacco paid a higher premium.The interesting thing here is that I didn't have to go through a physical exam to get the insurance. However, when I was working in the vet clinic and obtained AVMA insurance through my employer, I had to have blood and urine samples taken - for HIV, for drug use, and for common metabolic diseases such as diabetes or hypercholesterolemia. I wonder if the difference was because my current employer is a very large corporation, while the clinics are SBO's. I remember my boss complaining that he had to pay a higher premium because so many of his staff were overweight and/or smoked. He was always careful with his own health, and had difficulty understanding why others weren't. </td></tr></tbody></table></td></tr></tbody></table> <table width="100%" border="0" cellspacing="0" cellpadding="0"><tbody><tr><td><table width="100%" border="0" cellspacing="0" cellpadding="0"><tbody><tr><td width="180"></td><td width="14"></td><td width="0"><b>RE: COST of an Insurance Policy </b></td><td nowrap="nowrap" width="200">Sandy Williamson</td><td width="185">3/21/2013 5:32:16 PM</td></tr></tbody></table></td></tr><tr><td><table width="100%" border="0" cellspacing="0" cellpadding="0"><tbody><tr><td width="203"></td><td>Wow what a tough place to work. I saw on the news today where a company was making their employees weigh in or pay a 50.00 penalty. It seems its really becoming prejudice against those who have weight problems. Is this legal?I can understand about smoking it can harm others with second hand smoke. They claimed their weight was costing the employer money due to them developing diabetes, which is true but I am thin and I still suffer with diabetes and high blood pressure and high cholesterol and I have never been over 133lbs. This doesn't seem fair to me. </td></tr></tbody></table></td></tr></tbody></table> <table width="100%" border="0" cellspacing="0" cellpadding="0"><tbody><tr><td><table width="100%" border="0" cellspacing="0" cellpadding="0"><tbody><tr><td width="235"></td><td width="14"></td><td width="0"><b>RE: COST of an Insurance Policy </b></td><td nowrap="nowrap" width="200">Stephanie Lynch</td><td width="185">3/24/2013 6:21:49 PM</td></tr></tbody></table></td></tr><tr><td><table width="100%" border="0" cellspacing="0" cellpadding="0"><tbody><tr><td width="258"></td><td>We may see other companies start to do this, if CVS can pull this off and not cause too much PR trouble for themselves. I am for companies that want to work with employees to make themselves healthier. My company has a health center that we get a discount rate on using. We also have access to other things, like mentors and classes through the hospital.There is one company that I have heard about that has treadmills at all the desk instead of chairs, even in the conference rooms. </td></tr></tbody></table></td></tr><tr><td><table width="100%" border="0" cellspacing="0" cellpadding="0"><tbody><tr><td width="70"></td><td width="14"></td><td width="0"><b>RE: COST of an Insurance Policy </b></td><td nowrap="nowrap" width="200">Fredrick Casteel</td><td width="185">3/20/2013 2:30:55 PM</td></tr></tbody></table></td></tr><tr><td><table width="100%" border="0" cellspacing="0" cellpadding="0"><tbody><tr><td width="93"></td><td>An underwriter must gather information on the purposed individual to determine an adequate, competitive and equitable rate for the insured. The insured/uninsured must provide the underwriter with his/her health status, their ability to pay (work income or personal income), availability of other coverage, and historical persistency. An underwriter must gather this information from the insured/uninsured to better assist them in selecting the right heath plan they will need.Kongstvedt, P. (2007). Essentials of Managed Health Care 5^th edition p.572 </td></tr></tbody></table></td></tr></tbody></table> <table width="100%" border="0" cellspacing="0" cellpadding="0"><tbody><tr><td><table width="100%" border="0" cellspacing="0" cellpadding="0"><tbody><tr><td width="70"></td><td width="14"></td><td width="0"><b>RE: COST of an Insurance Policy </b></td><td nowrap="nowrap" width="200">Jorge Amador</td><td width="185">3/20/2013 7:00:41 PM</td></tr></tbody></table></td></tr><tr><td><table width="100%" border="0" cellspacing="0" cellpadding="0"><tbody><tr><td width="93"></td><td>The main four items when determining the cost of a policy by underwriters are: 1. Health Status 2. Ability to Pay 3. Availability of other Coverage (if any) 4. Historical Persistency (applies mainly to groups with high startup costs) (Kongstvedt 572-573). It primarily applies to how someone's health is and the ability of those individuals to be able to pay for the coverage they seek, comparing the other options that are readily available to the customer would make the cost be competitive and not over priced. It is incredible the differences between high risk like tobacco users and non smokers in the amount they spend to cover themselves. I believe that this could be more open and understand that not everyone will be as healthy and that they may still not be able to pay a high price so there is where the question becomes, what or how will those people get coverage? Kongstvedt, P. (2007). Essentials of Managed Health Care 5th edition </td></tr></tbody></table></td></tr><tr><td><table width="100%" border="0" cellspacing="0" cellpadding="0"><tbody><tr><td width="70"></td><td width="14"></td><td width="0"><b>RE: COST of an Insurance Policy </b></td><td nowrap="nowrap" width="200">Antonio Walker</td><td width="185">3/21/2013 9:21:54 PM</td></tr></tbody></table></td></tr><tr><td><table width="100%" border="0" cellspacing="0" cellpadding="0"><tbody><tr><td width="93"></td><td>Mrs. Warren,Underwriters use computer aggregated data to determine the probability and level of a disbursement over the life of an insurance plan. Underwriters use age, sex, health history and geographical location to determine the cost of the policy. The underwriter's main purpose is to protect the insurance company against risk and other parties who may have deceptive intentions. </td></tr></tbody></table></td></tr></tbody></table> <table width="100%" border="0" cellspacing="0" cellpadding="0"><tbody><tr><td><table width="100%" border="0" cellspacing="0" cellpadding="0"><tbody><tr><td width="125"></td><td width="14"></td><td width="0"><b>RE: COST of an Insurance Policy </b></td><td nowrap="nowrap" width="200">Professor Johnson-Warren</td><td width="185">3/22/2013 11:08:57 PM</td></tr></tbody></table></td></tr><tr><td><table width="100%" border="0" cellspacing="0" cellpadding="0"><tbody><tr><td width="148"></td><td>Thanks Antonio for your comment.You are correct. They must protect the insurance company against risks. However, although it is more excepted with auto, home and life insurance to deny coverage for high risks individuals why do we frown upon it with health care insurance? Could the term ethical be used in this argument? </td></tr></tbody></table></td></tr></tbody></table> <table width="100%" border="0" cellspacing="0" cellpadding="0"><tbody><tr><td><table width="100%" border="0" cellspacing="0" cellpadding="0"><tbody><tr><td width="180"></td><td width="14"></td><td width="0"><b>RE: COST of an Insurance Policy </b></td><td nowrap="nowrap" width="200">Antonio Walker</td><td width="185">3/23/2013 6:10:22 PM</td></tr></tbody></table></td></tr><tr><td><table width="100%" border="0" cellspacing="0" cellpadding="0"><tbody><tr><td width="203"></td><td>Mrs. Warren,Underwriting is frown upon when denying coverage for high risks individuals, because it seems to be a way of discriminating. The underwriting process may potentially assign these individuals to progressively higher risk-graded premium category, which makes it unaffordable. Therefore, it would be viewed in some cases as unethical. “Prohibitions against unfair discrimination in underwriting and classification are written into various federal and state statutes and regulations pertaining to health and disability insurance including the Americans with Disabilities Act (“ADA”) and state unfair insurance practices acts (Kirsch, n.d.).” This law is a way of requiring consistency and justification in underwriting with federal and state laws.Kirsch, L. (n.d.) Assessing the Actuarial Basis for Health-Related Underwriting in Medical and Disability Insurance. Retrieved March 23, 2013 from<a href="http://www.bazelon.org/LinkClick.aspx?fileticket=R9YQS4gzb44%3D&tabid=345">http://www.bazelon.org/LinkClick.aspx?fileticket=R9YQS4gzb44%3D&tabid=345</a> </td></tr></tbody></table></td></tr></tbody></table> <table width="100%" border="0" cellspacing="0" cellpadding="0"><tbody><tr><td><table width="100%" border="0" cellspacing="0" cellpadding="0"><tbody><tr><td width="235"></td><td width="14"></td><td width="0"><b>RE: COST of an Insurance Policy </b></td><td nowrap="nowrap" width="200">David Judkins</td><td width="185">3/24/2013 12:05:18 PM</td></tr></tbody></table></td></tr><tr><td><table width="100%" border="0" cellspacing="0" cellpadding="0"><tbody><tr><td width="258"></td><td>I agree Antonio. An when it comes to home, auto , and life insurance, the insurance company can assign predictable risk categories such as the color and make of an auto subject to being stolen or increased traffic violations; or homes that are in high flood areas, or with the average life span of an individual. But the subject of health becomes much more subjective. Health problems can start at any time in a persons life and many become life long problems. I would imagine that because there is the potential for to be many high risk cases and unpredictable risk cases in healthcare, it opens the door for more unethical practices and discrimination with health insurance. </td></tr></tbody></table></td></tr><tr><td><table width="100%" border="0" cellspacing="0" cellpadding="0"><tbody><tr><td width="235"></td><td width="14"></td><td width="0"><b>RE: COST of an Insurance Policy </b></td><td nowrap="nowrap" width="200">Letitia Armour</td><td width="185">3/24/2013 10:12:30 PM</td></tr></tbody></table></td></tr><tr><td><table width="100%" border="0" cellspacing="0" cellpadding="0"><tbody><tr><td width="258"></td><td>Antonio,Great information. Underwriting appears to sometimes take advantage of their position by denying coverage based upon high risk individuals who have major medical issues. This is a way of cutting those with more medical issues and higher premiums. And there are many people whom is not actaware of their rights, to contact "ADA," so they can be protected from this type of discrimination. Years ago Healthcare managed care organization and insurance companies focus on quality of healthcare for its consumers and patients. </td></tr></tbody></table></td></tr><tr><td><table width="100%" border="0" cellspacing="0" cellpadding="0"><tbody><tr><td width="180"></td><td width="14"></td><td width="0"><b>RE: COST of an Insurance Policy </b></td><td nowrap="nowrap" width="200">Guertty Lopez</td><td width="185">3/23/2013 6:45:06 PM</td></tr></tbody></table></td></tr><tr><td><table width="100%" border="0" cellspacing="0" cellpadding="0"><tbody><tr><td width="203"></td><td>As the professor pointed out, we frown upon it more when it comes to healthcare because for example, you can be healthy for many years and all of a sudden turn sick due to your genetics or an accident. This happened to me. I was always a healthy person and in 2005, I had an accident & injured my back. Ever since the accident, I've had other things appear like knee issues, chronic sinus (I also hit my head during the accident), etc. and ever since, I've always had a really hard time with the insurance when paying my claims. I always get a letter from them inquiring as to whether my follow up visits and medication are due to an accident that happened 8 yrs ago! The doctors know that my back is definitely a problem that was caused by the accident, but we've never known whether the rest of the issues that I have encountered are also things that have slowly deteriorated due to the impact of the accident. It could be due to other things, but the insurance automatically considers it as a pre-existing condition and eventually doesn't pay the claim, although I go through the studies and everyone tells me that it's covered prior to the visits. Bad things happen to good people and also certain illnesses are sometimes beyong our control. The industry just decides to oversee these types of incidences in order to avoid risk to the company. I'm lucky that I haven't had to undergo any other procedure or surgery since. </td></tr></tbody></table></td></tr></tbody></table> <table width="100%" border="0" cellspacing="0" cellpadding="0"><tbody><tr><td><table width="100%" border="0" cellspacing="0" cellpadding="0"><tbody><tr><td width="180"></td><td width="14"></td><td width="0"><b>RE: COST of an Insurance Policy </b></td><td nowrap="nowrap" width="200">Nikki Hetzer</td><td width="185">3/23/2013 10:13:04 PM</td></tr></tbody></table></td></tr><tr><td><table width="100%" border="0" cellspacing="0" cellpadding="0"><tbody><tr><td width="203"></td><td>Yes. I believe it is frowned upon because we are then talking about someone's life. To not insure or set very high premiums with an auto insurance it is not frowned upon as I am sure some people even believe there is some justice- as in if the person caused or got in a lot of accidents it is his or her fault- so it's justice. It is not justice to not insure someone or make the premiums extremely high for a sick person. In most cases it's not that person's fault but even if it is no one deserves to be sick or die because they can not afford health care coverage. </td></tr></tbody></table></td></tr><tr><td><table width="100%" border="0" cellspacing="0" cellpadding="0"><tbody><tr><td width="180"></td><td width="14"></td><td width="0"><b>RE: COST of an Insurance Policy </b></td><td nowrap="nowrap" width="200">Peru Tuika-Soske</td><td width="185">3/24/2013 6:46:44 AM</td></tr></tbody></table></td></tr><tr><td><table width="100%" border="0" cellspacing="0" cellpadding="0"><tbody><tr><td width="203"></td><td>Professor,I would have to agree with my classmates on how they answered this question. Frowning upon those who are denied or charged way too much for health insurance can be seen as, as not ethical for many reasons as they have stated. Our health issues can mostly be out of our control and there is just nothing we can do about it. Should be punished for that? No. We need to protect ourselves as much as we can especially if we have pre-existing conditions not due to any of our faults but those of genetics or accidents. </td></tr></tbody></table></td></tr></tbody></table> <table width="100%" border="0" cellspacing="0" cellpadding="0"><tbody><tr><td><table width="100%" border="0" cellspacing="0" cellpadding="0"><tbody><tr><td width="180"></td><td width="14"></td><td width="0"><b>RE: COST of an Insurance Policy </b></td><td nowrap="nowrap" width="200">Sheriker Bellard</td><td width="185">3/24/2013 7:37:12 PM</td></tr></tbody></table></td></tr><tr><td><table width="100%" border="0" cellspacing="0" cellpadding="0"><tbody><tr><td width="203"></td><td>I think ethically we frown upon being denied for healthcare due to the fact that we all need some form of healthcare in order to be secured in seeking healthcare. Being denied healthcare is seems to mean that as a culture we are denying someone some form of health regardless of the amount of money, where they come from as an American. </td></tr></tbody></table></td></tr><tr><td><table width="100%" border="0" cellspacing="0" cellpadding="0"><tbody><tr><td width="70"></td><td width="14"></td><td width="0"><b>RE: COST of an Insurance Policy </b></td><td nowrap="nowrap" width="200">Letitia Armour</td><td width="185">3/22/2013 8:29:05 AM</td></tr></tbody></table></td></tr><tr><td><table width="100%" border="0" cellspacing="0" cellpadding="0"><tbody><tr><td width="93"></td><td>Professor Johnson-Warren,The underwriters function is to use the information collected from several sources to determine whether or not to accept a particular applicant. They have to review several criteria to determine cost. 1) age and gender; 2) Medical history; 3) Family history; and 4) occupation. There are other determinate that factor into the decisions that underwriters makes too. Insurance companies in business to make money; therefore, it is the job of the underwriters to save on cost and make sure they charge accordingly.<a href="https://www.dcu.org/streetwise/insurance/info/eligibility.html">https://www.dcu.org/streetwise/insurance/info/eligibility.html</a> </td></tr></tbody></table></td></tr></tbody></table> <table width="100%" border="0" cellspacing="0" cellpadding="0"><tbody><tr><td><table width="100%" border="0" cellspacing="0" cellpadding="0"><tbody><tr><td width="70"></td><td width="14"></td><td width="0"><b>RE: COST of an Insurance Policy </b></td><td nowrap="nowrap" width="200">David Judkins</td><td width="185">3/22/2013 5:41:13 PM</td></tr></tbody></table></td></tr><tr><td><table width="100%" border="0" cellspacing="0" cellpadding="0"><tbody><tr><td width="93"></td><td>The text states that an uderwiter uses the following information to help determine rates for the individual or group:Health statusAbility to pay the premiumAvailability of other coverage (if any)Historical persistency (applies mainly to groups with high start-up costs) (Kongstvedt 572) </td></tr></tbody></table></td></tr><tr><td><table width="100%" border="0" cellspacing="0" cellpadding="0"><tbody><tr><td width="70"></td><td width="14"></td><td width="0"><b>RE: COST of an Insurance Policy </b></td><td nowrap="nowrap" width="200">Lisa Kieffer</td><td width="185">3/23/2013 9:10:17 PM</td></tr></tbody></table></td></tr><tr><td><table width="100%" border="0" cellspacing="0" cellpadding="0"><tbody><tr><td width="93"></td><td>Effective underwriting at issue determines the following information for the individual or group:• Health status• Ability to pay the premium• Availability of other coverage (if any)• Historical persistency (applies mainly to groups with high start-up costs)(Kongstvedt 572)Kongstvedt, Peter R.. ESSENTIALS MANAGED HEALTH CARE 5E VITALBOOKS, 5th Edition. Jones & Bartlett Publishers, 12/2007. <vbk:9780763797928#outline(30.2.1)>. </td></tr></tbody></table></td></tr></tbody></table> <table width="100%" border="0" cellspacing="0" cellpadding="0"><tbody><tr><td><table width="100%" border="0" cellspacing="0" cellpadding="0"><tbody><tr><td width="70"></td><td width="14"></td><td width="0"><b>RE: COST of an Insurance Policy </b></td><td nowrap="nowrap" width="200">Nikki Hetzer</td><td width="185">3/23/2013 9:32:35 PM</td></tr></tbody></table></td></tr><tr><td><table width="100%" border="0" cellspacing="0" cellpadding="0"><tbody><tr><td width="93"></td><td>Underwriters use the following items when determining the cost of a policy: health status, ability to pay the premium, availability of other coverage, and historical persistency. They use these items to predict how much money these individual people will cost them in the future and to be able to set their premiums so they will lose the least amount of money possible. </td></tr></tbody></table></td></tr><tr><td><table width="100%" border="0" cellspacing="0" cellpadding="0"><tbody><tr><td width="70"></td><td width="14"></td><td width="0"><b>RE: COST of an Insurance Policy </b></td><td nowrap="nowrap" width="200">Keniyotha Williams</td><td width="185">3/23/2013 9:53:11 PM</td></tr></tbody></table></td></tr><tr><td><table width="100%" border="0" cellspacing="0" cellpadding="0"><tbody><tr><td width="93"></td><td>Unfortunately, sex determines the cost of premiums. I found an interesting article in which a husband's company was no longer able to give affordable healthcare coverage. The wife started a search for insurance. She had never been hospitalized, but had fibromyalgia (muscle joint pain) that was controlled by medication. On the other hand, her husband was hospitalized three times for kidney stones and had an appendectomy. He was also a smoker. When the wife applied, she was rejected six times. Her husband applied for the same insurance companies and he was accepted by the policies that rejected his wife. The wife reapplied to the same companies as a woman and a man with the same complications. She was rejected as a woman all six times and accepted as a man 2 of the 6 times.Women are charged more or turned down altogether because women go to the doctor more, take medication (birth control pills), while men visit the doctor more when they get in their mid 50s. It is a way that the insurance companies cut costs. Research shows that preexisting conditions in women trigger denials when compared to preexisting conditions in men.Deam, J. (2011). Preexisting condition: Female. <i>Prevention</i>. 63(12); 28-38. </td></tr></tbody></table></td></tr></tbody></table> <table width="100%" border="0" cellspacing="0" cellpadding="0"><tbody><tr><td><table width="100%" border="0" cellspacing="0" cellpadding="0"><tbody><tr><td width="125"></td><td width="14"></td><td width="0"><b>RE: COST of an Insurance Policy </b></td><td nowrap="nowrap" width="200">Sherita Swinton</td><td width="185">3/24/2013 10:57:59 AM</td></tr></tbody></table></td></tr><tr><td><table width="100%" border="0" cellspacing="0" cellpadding="0"><tbody><tr><td width="148"></td><td>Keniyotha,This was a very informative post! You provided some information that I had no idea about. I never consider the fact that gender can determine one's cost of insurance premiums. The article you provided was very interesting information for me. I appreciate you making me aware and putting some things into perspective for me.Sherita </td></tr></tbody></table></td></tr><tr><td><table width="100%" border="0" cellspacing="0" cellpadding="0"><tbody><tr><td width="15"></td><td width="14"></td><td width="0"><b>Capitation </b></td><td nowrap="nowrap" width="200">Laura Wimberly</td><td width="185">3/19/2013 8:32:56 PM</td></tr></tbody></table></td></tr><tr><td><table width="100%" border="0" cellspacing="0" cellpadding="0"><tbody><tr><td width="38"></td><td>Capitation is known as someone delivering care whereas physicians have an important role to play in managing the risk assumed by the MCO, by providing medical management to members in a cost conscious manner. Some concerns need to be addressed when implementing capitation are the following:It is the specialist fear that when they accept capitation, they are at risk for overutilization by the primary care physician.A specialist must clearly understand the full costs of his or her operation in order to monitor the capitation rate accepted.Initially the provision of quality medical services under a capitation may seem excessively costly, and unfortunately there may appear to be incentive to cut costs by reducing services.Source: Managed Care Contracting – Specialty Capitation in a Managed Care Environment by Ira H. Rosenberg (<a href="http://www.mcres.com/mcrmcc09.htm">http://www.mcres.com/mcrmcc09.htm</a> ) </td></tr></tbody></table></td></tr></tbody></table> <table width="100%" border="0" cellspacing="0" cellpadding="0"><tbody><tr><td><table width="100%" border="0" cellspacing="0" cellpadding="0"><tbody><tr><td width="70"></td><td width="14"></td><td width="0"><b>RE: Capitation </b></td><td nowrap="nowrap" width="200">Tatiania Tabb</td><td width="185">3/20/2013 2:56:55 PM</td></tr></tbody></table></td></tr><tr><td><table width="100%" border="0" cellspacing="0" cellpadding="0"><tbody><tr><td width="93"></td><td>Laura, I found your above post very informative and well written. Capitation is something that physicians have to play close attention to because there salaries could be affected. Like many people I believe that no one wants to work and not be paid correctly according to your salary guidelines. With the constant changes in Capitation; I believe that physicians should always be aware of how capitation is affecting there practice. </td></tr></tbody></table></td></tr><tr><td><table width="100%" border="0" cellspacing="0" cellpadding="0"><tbody><tr><td width="70"></td><td width="14"></td><td width="0"><b>RE: Capitation </b></td><td nowrap="nowrap" width="200">Julie Gildemeister</td><td width="185">3/22/2013 11:44:21 AM</td></tr></tbody></table></td></tr><tr><td><table width="100%" border="0" cellspacing="0" cellpadding="0"><tbody><tr><td width="93"></td><td>Laura, I think I read the same resource you linked us to.One thing that I saw repeatedly in veterinary medicine, and also in the human healthcare field, is the physicians' lack of business knowledge. It makes it difficult for them to understand the trade-offs between various payment methods. One common mistake is the assumption that the revenue charged (i.e. services rendered) does not always match the revenue actually paid. In other words, you can perform every service in your arsenal, but you are at risk until the patient pays you for those services.The thing about the insurance industry, especially in decades past when insurance reimbursed on the FFS system, is that physicians did not have to think about how much the total bill was going to be. In veterinary medicine, we have to think about the total costs and whether or not the client will be able to afford it. That is why over the past twenty years the custom of presenting itemized estimates for hospitalizations and procedures have become part of the standard of practice. We are not allowed to take on a patient until we have authorization from the owner for the services we intend to perform.In the current economic reality, are specialists facing more nonpayment of bills? Are they turning more accounts over to collections because their patients can not afford to pay the balance after the insurance pays for it? How much of their performed revenue can they afford to lose to accounts receivable before they start to go under? There may be times when capitation, with its more consistent cash flow, may be a better arrangement than FFS, especially when AR starts to get out of control. </td></tr></tbody></table></td></tr></tbody></table> <table width="100%" border="0" cellspacing="0" cellpadding="0"><tbody><tr><td><table width="100%" border="0" cellspacing="0" cellpadding="0"><tbody><tr><td width="70"></td><td width="14"></td><td width="0"><b>RE: Capitation </b></td><td nowrap="nowrap" width="200">Satchit Ladwa</td><td width="185">3/23/2013 10:39:00 PM</td></tr></tbody></table></td></tr><tr><td><table width="100%" border="0" cellspacing="0" cellpadding="0"><tbody><tr><td width="93"></td><td>Good explanation, Laura. Sometimes doctors reach an agreement with a managed care organization called capitation, in which the doctor is paid per person. Under this agreement, doctors accept members of the plan for a certain set price per member, no matter how often the member sees the doctor. For example, the doctor may be paid $20 per member every month and that amount doesn't change if the member comes in for five appointments that month or none.http://www.faqs.org/health/Healthy-Living-V2/Health-Care-Systems-Managed-health-care-vs-fee-for-service.html </td></tr></tbody></table></td></tr><tr><td><table width="100%" border="0" cellspacing="0" cellpadding="0"><tbody><tr><td width="15"></td><td width="14"></td><td width="0"><b>Problems with MCOs and specialty care practices </b></td><td nowrap="nowrap" width="200">Keniyotha Williams</td><td width="185">3/19/2013 9:26:13 PM</td></tr></tbody></table></td></tr><tr><td><table width="100%" border="0" cellspacing="0" cellpadding="0"><tbody><tr><td width="38"></td><td>When specialty care practices meet with MCOs, there many adjustments that have to be made. The highest adjustment on the list is the reduction in reimbursements. Fee-for-service is practically null and void.. Physicians have to agree to accept lower payments for services. Also, there is a primary gatekeeper, which may limit the amount of referrals the specialists could receive. When teaming up with MCO, there is an increased professional risk. Ordering diagnostic tests and suggesting additional referrals "to be sure" are scrutinized through the referral and utilization management process by MCO. Specialists have to abide by the medical service in accordance to the clinical pathways and not the professional judgment itself.<a href="http://www.mcres.com/mcrmcc09htm">http://www.mcres.com/mcrmcc09htm</a> </td></tr></tbody></table></td></tr></tbody></table> <table width="100%" border="0" cellspacing="0" cellpadding="0"><tbody><tr><td><table width="100%" border="0" cellspacing="0" cellpadding="0"><tbody><tr><td width="70"></td><td width="14"></td><td width="0"><b>RE: Problems with MCOs and specialty care practices </b></td><td nowrap="nowrap" width="200">Jose Valderama-Sierra</td><td width="185">3/23/2013 7:09:16 PM</td></tr></tbody></table></td></tr><tr><td><table width="100%" border="0" cellspacing="0" cellpadding="0"><tbody><tr><td width="93"></td><td>Recently ive been rejected my TJM surgery because prior to signing up to my health insurance back in 2011 i told them i was having TMJ issues. And now that i need the surgery asap they are rejecting me because its precondition before i signed up with my health insurance back in 2011.Ive inquired several times that i shouldnt be rejected anymore with the new obama care and only response i get is that, "that will kick in in 2014". Is this right? I cant keep going on with these horrible head aches! </td></tr></tbody></table></td></tr></tbody></table> <table width="100%" border="0" cellspacing="0" cellpadding="0"><tbody><tr><td><table width="100%" border="0" cellspacing="0" cellpadding="0"><tbody><tr><td width="125"></td><td width="14"></td><td width="0"><b>RE: Problems with MCOs and specialty care practices </b></td><td nowrap="nowrap" width="200">Keniyotha Williams</td><td width="185">3/23/2013 9:23:28 PM</td></tr></tbody></table></td></tr><tr><td><table width="100%" border="0" cellspacing="0" cellpadding="0"><tbody><tr><td width="148"></td><td>Jose, unfortunately, that is correct. I looked at an article for the post and the Obama Care Act in which pre-existing conditions doesn't matter, starts in 2014. The insurance companies will continue to avoid costs for the remaining of the year. Hopefully, you could tolerate the pain a little longer to receive the care needed. In the meantime, you could research natural methods that would ease the pain until the new policy kicks in. </td></tr></tbody></table></td></tr><tr><td><table width="100%" border="0" cellspacing="0" cellpadding="0"><tbody><tr><td width="15"></td><td width="14"></td><td width="0"><b>Problems MCOs experience when implementing capitation arrangements in specialty care practices </b></td><td nowrap="nowrap" width="200">Nikki Hetzer</td><td width="185">3/20/2013 10:29:53 PM</td></tr></tbody></table></td></tr><tr><td><table width="100%" border="0" cellspacing="0" cellpadding="0"><tbody><tr><td width="38"></td><td>Capitation arrangements in specialty care practices, puts the specialists at greater risk, because if a specialist contracts with an MCO, he or she must accept reductions in reimbursement levels, he or she can not order any diagnostic test- hence the professional risk increases and patients are controlled through primary care providers. Fee-for-service rate schedules as determined by the specialist are virtually non-existent. Today, managed care organizations usually reimburse from a fixed fee schedule, as established by the HMO. Source: <a href="http://www.mcres.com/mcrmcc09.htm">http://www.mcres.com/mcrmcc09.htm</a> </td></tr></tbody></table></td></tr></tbody></table> <table width="100%" border="0" cellspacing="0" cellpadding="0"><tbody><tr><td><table width="100%" border="0" cellspacing="0" cellpadding="0"><tbody><tr><td width="70"></td><td width="14"></td><td width="0"><b>RE: Problems MCOs experience when implementing capitation arrangements in specialty care practices </b></td><td nowrap="nowrap" width="200">Brenda Grant</td><td width="185">3/22/2013 5:08:03 PM</td></tr></tbody></table></td></tr><tr><td><table width="100%" border="0" cellspacing="0" cellpadding="0"><tbody><tr><td width="93"></td><td>This does put a very tight reign on specialists. A referral is necessary for an and all diagnostic testing which may be needed for appropriate care. This can slow the process of care and possibly recovery time for the patient. </td></tr></tbody></table></td></tr><tr><td><table width="100%" border="0" cellspacing="0" cellpadding="0"><tbody><tr><td width="70"></td><td width="14"></td><td width="0"><b>RE: Problems MCOs experience when implementing capitation arrangements in specialty care practices </b></td><td nowrap="nowrap" width="200">Teresa O'Brien</td><td width="185">3/24/2013 7:29:58 PM</td></tr></tbody></table></td></tr><tr><td><table width="100%" border="0" cellspacing="0" cellpadding="0"><tbody><tr><td width="93"></td><td>Hi Nikki - This was an interesting article on how Physicians have an important role to play in managing this risk assumed by the MCO, by providing medical management to members in a cost conscious manner, the sharing of which is called capitation. Fee-for-service rate schedules as determined by the specialist are virtually non-existent, which is the most attractive to providers because they do not bear the burden of the risk. (retrieved from source <a href="http://www.mcres.com/mcrmcc09.htm">http://www.mcres.com/mcrmcc09.htm</a>)With MCOs, Physicians have increased professional risk. <i>“The ordering of diagnostic tests and additional referrals "just to be sure", is scrutinized by the MCOs through their referral and utilization management processes. In many ways the physician is held to higher standards in servicing a patient, standards with which many of them do not agree, and are not accustomed to meeting. Additionally, clinical pathways by disease, stipulating what some refer to as "recipes" for services, are now being widely recognized and utilized, requiring the specialist to provide medical service in accordance to the MCO's clinical pathways, and not necessarily to his or her professional judgement alone.” </i> In my opinion, this sounds like it is literally taking the control for making patient care decisions from the physician in its entirety. </td></tr></tbody></table></td></tr><tr><td><table width="100%" border="0" cellspacing="0" cellpadding="0"><tbody><tr><td width="15"></td><td width="14"></td><td width="0"><b>RE: Managed-Care Underwriting </b></td><td nowrap="nowrap" width="200">Latia Phelps</td><td width="185">3/20/2013 5:59:22 PM</td></tr></tbody></table></td></tr><tr><td><table width="100%" border="0" cellspacing="0" cellpadding="0"><tbody><tr><td width="38"></td><td><b>Modified:</b>3/20/2013 6:07 PM</td></tr><tr><td width="38"></td><td>Problems that MCA have experience in regards to specialty care practices include a referral has to be made by the PCP or primary care physician. According to Capitation Payment in Managed Care Systems, "Relatively few physicians are paid on a fully capitated basis. It is important to understand, however, that the HMOs themselves ARE paid on such a manner (although many do purchase re-insurance to protect themselves against higher-than-anticipated expenses.) Because of this, there is often tension between HMOs themselves and their physician panel. The successful operation of an HMO depends, then, to a large degree on whether the HMO can transfer some of its financial incentive to conserve resources to its physician panel, while at the same time not generating enmity from members of the panel.(<a href="http://www.otohns.net/default.asp?id=15510">http://www.otohns.net/default.asp?id=15510</a>) </td></tr></tbody></table></td></tr></tbody></table> <table width="100%" border="0" cellspacing="0" cellpadding="0"><tbody><tr><td><table width="100%" border="0" cellspacing="0" cellpadding="0"><tbody><tr><td width="15"></td><td width="14"></td><td width="0"><b>Goal of insurance rates </b></td><td nowrap="nowrap" width="200">Professor Johnson-Warren</td><td width="185">3/22/2013 5:33:04 PM</td></tr></tbody></table></td></tr><tr><td><table width="100%" border="0" cellspacing="0" cellpadding="0"><tbody><tr><td width="38"></td><td>Insurance rates are, typically, set high enough to generate sufficient revenue, cover all claims and other plan expenses, and yield an acceptable return on equity. Please explain why it is important to meet these goals. </td></tr></tbody></table></td></tr></tbody></table> <table width="100%" border="0" cellspacing="0" cellpadding="0"><tbody><tr><td><table width="100%" border="0" cellspacing="0" cellpadding="0"><tbody><tr><td width="70"></td><td width="14"></td><td width="0"><b>RE: Goal of insurance rates </b></td><td nowrap="nowrap" width="200">Laura Wimberly</td><td width="185">3/23/2013 10:32:42 AM</td></tr></tbody></table></td></tr><tr><td><table width="100%" border="0" cellspacing="0" cellpadding="0"><tbody><tr><td width="93"></td><td> It’s important to meet the insurance rates because moving to far in any direction from successful underwriting and rating strikes a balance among adequancy, competitiveness, and equity of rates. While competitive rates are low enough to sell enough policies and enroll enough members to meet health plan volume and growth targets.Essentials of Managed Health Care by Peter Reid Kongstvedt </td></tr></tbody></table></td></tr></tbody></table> <table width="100%" border="0" cellspacing="0" cellpadding="0"><tbody><tr><td><table width="100%" border="0" cellspacing="0" cellpadding="0"><tbody><tr><td width="125"></td><td width="14"></td><td width="0"><b>RE: Goal of insurance rates </b></td><td nowrap="nowrap" width="200">Teresa O'Brien</td><td width="185">3/23/2013 3:30:57 PM</td></tr></tbody></table></td></tr><tr><td><table width="100%" border="0" cellspacing="0" cellpadding="0"><tbody><tr><td width="148"></td><td>It is important for insurance companies to develop premiums that will pay for losses and expenses and provide a margin for profit and contingencies. Otherwise they will not generate enough revenues to be able to afford to pay out claims when they do occur. Insurance organizations consider future claims, future expenses, profit, and contingencies when determining rates and are based on past loss experience. Determination and calculation of insurance rates is a professional role that actuaries and advisory organizations provide due the complexity of all of the variables. </td></tr></tbody></table></td></tr><tr><td><table width="100%" border="0" cellspacing="0" cellpadding="0"><tbody><tr><td width="125"></td><td width="14"></td><td width="0"><b>RE: Goal of insurance rates </b></td><td nowrap="nowrap" width="200">Latia Phelps</td><td width="185">3/23/2013 11:13:03 PM</td></tr></tbody></table></td></tr><tr><td><table width="100%" border="0" cellspacing="0" cellpadding="0"><tbody><tr><td width="148"></td><td>I agree with you Luara, f the rates are to high and unaffordable then people will weigh the options of the investment. f the policy deductible is low but the benefit only covers some of the services that are needed than this is not good either. There has to be a balance for the insurance to be profitable for both parties. </td></tr></tbody></table></td></tr><tr><td><table width="100%" border="0" cellspacing="0" cellpadding="0"><tbody><tr><td width="70"></td><td width="14"></td><td width="0"><b>RE: Goal of insurance rates </b></td><td nowrap="nowrap" width="200">Jorge Amador</td><td width="185">3/23/2013 10:58:46 AM</td></tr></tbody></table></td></tr><tr><td><table width="100%" border="0" cellspacing="0" cellpadding="0"><tbody><tr><td width="93"></td><td>Professor,It is imperative that an insurance rate is at the right level since people have different ways of utilizing their healthcare coverage such as seeking medical treatment for anything from a common cold to just a small twist of muscles but other people have a tendency of only going to the doctor when the issue does not resolve itself over time or over the treatment they have done for that kind of issues or illness. Insurance must be able to cover the claims that are done whether they are small or big so to make up for what they will be paying for the high utilization patient compared to the low utilization patient. If all people went to the doctor at the same type of rate it would have to be a much higher rate yet the people would be wondering why pay so high. For example we get low rates due to us being Unionized so our rates are low very similar to Managers who are not Unionized yet where it comes to a difference is with the Deductibles and Maximum Out of Pocket amounts. We have a very low Deductible and Out of Pocket for the year yet managers have about 3x or more of a Deductible and Out of Pocket Maximums. So the rates are not just the only things to consider Insurance taking into affect but also when they will start covering the percentage they are suppose to cover (Once deductible is met) and when as a patient we will not have to pay anything (Out of Pocket Maximum). </td></tr></tbody></table></td></tr></tbody></table> <table width="100%" border="0" cellspacing="0" cellpadding="0"><tbody><tr><td><table width="100%" border="0" cellspacing="0" cellpadding="0"><tbody><tr><td width="70"></td><td width="14"></td><td width="0"><b>RE: Goal of insurance rates </b></td><td nowrap="nowrap" width="200">Sheriker Bellard</td><td width="185">3/23/2013 5:40:52 PM</td></tr></tbody></table></td></tr><tr><td><table width="100%" border="0" cellspacing="0" cellpadding="0"><tbody><tr><td width="93"></td><td>It is extremely important to have the correct calculation of premiums because when patients present themselves to a facility or health organization, you would definitely think they would want their insurance claims paid. If premiums are underestimated it can cause an insurance to pay claims. Although premiums can be a bit pricey at times, it would cost a lot more to have to pay for services out of pocket without having any type of coverage. Often time hospital items are at least 10 time more than what they actually paid. An example would be 1 Tylenol for an inpatient stay could cost up to $9.00. Ensuring affordiability as well as remaining competitive with other insurance companies is the key as well as quoting the correct premiums to ensure that Insurance companies generate some form of revenue while at the same time providing patients great coverage. </td></tr></tbody></table></td></tr><tr><td><table width="100%" border="0" cellspacing="0" cellpadding="0"><tbody><tr><td width="70"></td><td width="14"></td><td width="0"><b>RE: Goal of insurance rates </b></td><td nowrap="nowrap" width="200">Lisa Kieffer</td><td width="185">3/24/2013 11:46:04 AM</td></tr></tbody></table></td></tr><tr><td><table width="100%" border="0" cellspacing="0" cellpadding="0"><tbody><tr><td width="93"></td><td>A health plan should continually assess its success in each of these areas. Although always important, this is particularly true for a newly established plan or product offering. For example, a plan cannot be sure whether a high volume of sales is good or bad until adequacy and equitability are assessed because competitive rates are not necessarily adequate or equitable.(Kongstvedt 572)Underwriting involves gathering information about applicants or groups of applicants to determine an adequate, competitive, and equitable rate at which to insure them. The type of underwriting and level of scrutiny depend on many factors, including the time at which the underwriting is done (at issue, during the plan year, or at renewal), the group size (individual, small, or large), and the risk arrangement (fully insured or self-insured).Even though there is over 14,000 employees of the company I work for and most are insured through the company, Humana is paying a great deal in claims. Last year I dislocated my shoulder and broke the shoulder. I was out for 12 weeks and additional physical therapy charges. Just in the last 3 years at my hospital a great deal of women are coming down with breast cancer. Many of these women had mastectomies and reconstructive surgery. Another large portion of us with more othro problems. The company takes care of us, but the premiums do rise every year. We are working but at the same time, we are falling apart as we get older.(Kongstvedt 572)Kongstvedt, Peter R.. ESSENTIALS MANAGED HEALTH CARE 5E VITALBOOKS, 5th Edition. Jones & Bartlett Publishers, 12/2007. <vbk:9780763797928#outline(30.2)>. Kongstvedt, Peter R.. ESSENTIALS MANAGED HEALTH CARE 5E VITALBOOKS, 5th Edition. Jones & Bartlett Publishers, 12/2007. <vbk:9780763797928#outline(30.1)>. </td></tr></tbody></table></td></tr></tbody></table> <table width="100%" border="0" cellspacing="0" cellpadding="0"><tbody><tr><td><table width="100%" border="0" cellspacing="0" cellpadding="0"><tbody><tr><td width="125"></td><td width="14"></td><td width="0"><b>RE: Goal of insurance rates </b></td><td nowrap="nowrap" width="200">Sandy Williamson</td><td width="185">3/24/2013 4:51:23 PM</td></tr></tbody></table></td></tr><tr><td><table width="100%" border="0" cellspacing="0" cellpadding="0"><tbody><tr><td width="148"></td><td>I fully understand the importance of the insurance companies keeping the right formulator for there profitability ratio. I worked for Lloyd of London in the US Virgin Islands back in 1992 after hurricane Hugo and the claims were so extensive that many of the local agents were forced to close do to the claims. This was also a big strain on Lloyds as well but they pulled through. So it is easy to realize has easy a epidemic would sink many health care providers/ insurance companies. </td></tr></tbody></table></td></tr><tr><td><table width="100%" border="0" cellspacing="0" cellpadding="0"><tbody><tr><td width="70"></td><td width="14"></td><td width="0"><b>RE: Goal of insurance rates </b></td><td nowrap="nowrap" width="200">Fredrick Casteel</td><td width="185">3/24/2013 8:08:52 PM</td></tr></tbody></table></td></tr><tr><td><table width="100%" border="0" cellspacing="0" cellpadding="0"><tbody><tr><td width="93"></td><td>I think it’s important that insurance companies meet these goals because it helps them to be able to handle the several billions of dollars they pay out each year for their customers. Since hospital rates are set differently, insurance companies must be able to pay for the service provided. They basically have to know the current rates for each treatment in the industry to make sure payment is cover to all. </td></tr></tbody></table></td></tr></tbody></table> <table width="100%" border="0" cellspacing="0" cellpadding="0"><tbody><tr><td><table width="100%" border="0" cellspacing="0" cellpadding="0"><tbody><tr><td width="70"></td><td width="14"></td><td width="0"><b>RE: Goal of insurance rates </b></td><td nowrap="nowrap" width="200">Nikki Hetzer</td><td width="185">3/24/2013 9:28:30 PM</td></tr></tbody></table></td></tr><tr><td><table width="100%" border="0" cellspacing="0" cellpadding="0"><tbody><tr><td width="93"></td><td>Insurance rates are, typically, set high enough to generate sufficient revenue, cover all claims and other plan expenses, and yield an acceptable return on equity. Please explain why it is important to meet these goals? It is important for insurance companies to meet those goals to cover all losses (and future losses) and expenses and still be able to provide a margin for profit. If this goal is not met the insurance companies would not be able to pay out claims when they occur. </td></tr></tbody></table></td></tr><tr><td><table width="100%" border="0" cellspacing="0" cellpadding="0"><tbody><tr><td width="15"></td><td width="14"></td><td width="0"><b>Week 3 Wrap Up </b></td><td nowrap="nowrap" width="200">Professor Johnson-Warren</td><td width="185">3/24/2013 4:13:15 PM</td></tr></tbody></table></td></tr><tr><td><table width="100%" border="0" cellspacing="0" cellpadding="0"><tbody><tr><td width="38"></td><td><p align="center">Underwriting is an important aspect of healthcare insurance. We are billed monthly in insurance premiums and rarely understand the plan we are paying for. Knowing how underwriter determine a your plan is a great gift. Let's jump right into WEEK 4 as we move forward!</p> </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table>
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