USHC Exam 2 pt. 2 questions correctly answered graded A+ to pass

USHC Exam 2 pt. 2 questions correctly answered graded A+ to passWhat is Medicaid? A health insurance program for low income people sponsored by state and federal government (jointly financed) Title XIX of Social Security Act Entitlement program (cannot legally enforce rights like you can in Medicare) Each state's program varies; subject to federal standards but each state designs and administers their own programs; flexibility in determining covered populations, services, health care delivery models, methods for paying, etc. State participation is voluntary but all participate (Last to do so was AZ) Serves 1 in 5 or 70 million Americans (lack access to other affordable health insurance) Finances over 16% of all personal health care spending in US What does Medicaid cover? Long-term care Early, periodic, screening, diagnosis and treatment (EPSDT) *For children *Mandatory program for all states *Any condition identified as part of an EPSDT screening must be covered, even if it is not traditionally a covered benefit in that state Who qualifies for Medicaid? Low income people Who benefits from Medicaid coverage? 1) U.S. Citizens 2) Means tested, categorical eligibility= must be both poor and a certain type of person; categorical eligibility is elminated under ACA 3) Federal requirements for certain kind of person *TANF recipients *SSI recipients *Children and pregnant women if income is at or below 133% of FPL *"Medically needy" designated by a state *The elderly, people with disabilities, children, pregnant women, and some parents-- limits b/f ACA Majority of Medicaid spending is on which groups? 1) 1 in 3 children in US 2) 48% of all births 3) More than 30% of long-term care 4) Mostly for the elderly and people with disabilities Financing Medicaid 1) Jointly financed 2) Federal Medical Assistance Percentage (FMAP) 3) Based on state's per capita income 4) Between 50-83% of total state costs 5) Actual FY 2019: 50% in several states, 76.39% in MS 6) States may also charge premiums and cost-sharing *Relationship between states with highest federal matching rate and state per capita income (states w/ lower per capita income have a higher federal matching rate) *Spending per-enrollee (has increased slower than national health expenditures per capita and private insurance per enrollee) Medicaid Expansion 1) 38 states and Washington D.C. have adopted ACA Medicaid Expansion 2) Prior to the ACA, Medicaid was limited to specific low-income groups (elderly, people with disabilities, children, pregnant women, and some parents) 3) Coverage gap: income above Medicaid eligibility but below poverty (more than 2 million poor uninsured adults fell into coverage gap); despite having low income, nearly two-thirds of people in the coverage gap are in a family with a worker, and half are working themselves *Adults left in the coverage gap are spread across the states not expanding their Medicaid programs but are concentrated in states with the largest uninsured populations. More than a third (33%) of people in coverage gap are in TX (large uninsured population and very limited Medicaid eligibility). 19%= FL *12% = GA *10% = NC **Those in gap live largely in the South (aka places that did not take up expansion) *There are no uninsured adults in the coverage gap in Wisconsin because the state is providing Medicaid eligibility to adults up to the poverty level under a Medicaid waiver. *The geographic distribution of the population in the coverage gap reflects both population distribution and regional variation in state take-up of the ACA Medicaid expansion. The South has relatively higher numbers of poor uninsured adults than in other regions, has higher uninsured rates and more limited Medicaid eligibility than other regions, and accounts for the majority (8 out of 12) of states that opted not to expand Medicaid. What states did not adopt ACA Medicaid Expansion? AL, GA, FL, KS, MS, NC, SC, SD, TN, TX, WI, WY (mostly South and Midwest) What states adopted but did not implement ACA Medicaid Expansion? OK, MO Medicaid Managed Care- details 1) Dominant way in which states deliver services to Medicaid enrollees 2) States adopt and administer their own programs within fed guidelines/rules. States determine how they will deliver and pay for care for Medicaid enrollees. 3) Almost all states have some form of managed care in place (comprehensive risk-based maanged care and/or primary care case management) 4) As of July 2021, 41 states (including DC) contracted with comprehensive risk-based managed care plans to provide care to at least some of Medicaid enrollees (aka managed care plans) 5) NC is latest state to be added to this count (did so in July 2021) Managed Care A health care system whose goals are to provide cost effective quality care. Medicaid Managed Care- defined and examples of contracts *Provides comprehensive acute care and sometimes long-term services and supports Medicaid beneficiaries *Accept a set per member per month payment for services and are at financial risk for Medicaid services in their contracts. *Risk-based contracting with managed care plans have many purposes: 1) Increase budget predictability 2) Constrain Medicaid spending 3) Improve access to care and value 4) Meet other objectives Increased budget predictability, but impact of managed care on access to care and costs is limited and mixed. MCOs and Medicaid Spending Nearly half of all Medicaid spending is for payments to MCOs Future of Medicaid 1) Major private investments in Medicaid Manage Care complicates federalism/ role of gov't 2) More commitment than ever since COVID-19 recession 3) Move away from direct link to most improverished changes political dynamic 4) Issues remain re payment and provider enrollment History of Medicare 1) Hill Burton Act: provided federal grants to states to create new community hospitals (nonfederal, short-stay) 2) Kerr-Mills: federal grants given to states to extend health services provided by states' welfare programs to low-income elderly folx who did not previously qualify for coverage/services; means test (eligibility depends on income) 3) Anderson-King: primary sponsors of Medicare; some hospital and nursing home costs for patients 65 and older would have been covered- defeated but close- you can see people are shifting their stances on the issue 4) Eldercare: federal-state program to subsidize private insurance policies for hospital and physician services Eligibility 1) 65 years and older 2) Disabled individuals who are entitled to Social Security benefits 3) Peopel who have end-stage renal disease (ESRD) What does Medicare cover? 1) Inpatient hospital 2) Skilled nursing home facility (after 3-day hospital stay) 3) Home health services (part time skilled nursing, home health aide, rehab therapies, medical equipment, social services, medical supplies) 4) Hospice care 5) Inpaitent psychiatric care (190-day lifetime limit) Medicare Part A - Hospital Insurance covers most medically necessary hospital care, skilled nursing facilities, home health and hospice care - Free if you have worked and paid social security for more than 10 years (40 calender quarters) - if less than montly premium will be paid Medicare Part B Supplementary Medical Insurance (SMI) - covers medical expenses, clinical lab, outpatient, blood, & ambulatory services Medicare Part C Medicare advantage plan, combo of part a and b. covers all medical services that are needed Medicare Part D Prescription drug coverage that helps pay for medications doctors prescribe for treatment. Enrollment is voluntary and an additional monthly premium must be paid. *Natioanl average for monthly premiums in 2017 was expected to be $42.17, 9% increase over the avg monthly premium in 2016. Who pays for Medicare? General taxes Payroll taxes Most benefit payments go to hospitals; next most goes to private Medicare Advantage plans Legislative, Executive, and Judicial Branches in Implementing Medicare ... Payments ... Medicare Advantage vs. Traditional Medicare ... History of Managed Care -prepaid group practice -Kaiser Permanente Health Plan -Group Health Association of Wash Dc -Slow growth of MCOs til 1970s -Health Insurance Plan (HIP) of Greater NY -Group Health Cooperative of Puget Sound -Rise of MCOs from '70s to '80s HMO Act of 1973 Pres Nixon: means of containing expenditures Sen Kennedy: means of creating plans with minimum benefits *Fed grants and loans to establish/expand HMOs *Fed laws override state laws restricting HMO creation *Established requirement to offer HMO plans as part of employer-sponsored insurance *Seen by established medicine as "radical" Pressure for Changing to Managed Care -Flaws in fee-for-service payment method -Uncontrolled utilization -Uncontrollable prices and payment -Focus on illness instead of wellness -Pressures on total expenditures and desire to shift financial risk -Decline in provider economic power -Organized approach to deliver a comprehensive array of health care services to members thru efficient mgmt of services need by members and negotiation of prices or payments arranged w/ providers Critiques of Managed Care -Does not always eliminate insurance intermediaries -Share Share risk with providers or extrant discounts: Finding a "tipping" point that actually drives behavior -Care coordination and delivery in appropriate setting: cost-effectiveness a challenge -Wellness and preventive services: the dream of the HMO pioneers Types of Managed Care -Health Maintenance Organization, -Preferred Provider Organization -Point-of-Service Plans Spread of Managed Care and Move Towards Value -In the Medicare program -In the Medicaid program -use of managed care by commerical insurance-including PPOs as a form of managed care -Limited spread of the classic HMO model -Hybrids: Point-of-service, primary care case management -Evolution from focus on expenditure only to focus on return on investment (value equation) -Driving public payment reforms and private insurance activity Accountable Care Organization (ACO) An integrated group of providers who are willing and able to take responsibility for improving the overall health status, care efficiency, and satisfaction with care for a defined population. Basic elements of ACOs -Responsible for all Medicare payment for a specific or attributed population -Minimum of 5,000 beneficiaries -Savings return is a function of meeting quality metrics as well as spending targets -Not sharing full consequences of financial risk -In Medicare, beneficiaries are attributed to the ACO based on where they receive primary care services but are allowed to seek services from any provider -ACOs may create incentives to recieve care from ACO providers Effects on payment to providers -Model focuses on total expenditures, not individual fee-for-service payment -Shared savings model=savings from a projected total expenditure amount are shared -Accountable means that the savings are shared based on meeting quality metrics and can be adjusted based on quality metric scores -Shared means providers accept financial risk; exists for all ACOs Effects on patient care -Meeting quality metrics has resulted in measured improvement in quality -Focus on total expenditures creates incentives to eliminate potentially avoidable utilization of expensive services (e.g., hospital emergency rooms and inpatient services) -Puts premium on care management, particularly of beneficiaries with chronic conditions and therefore likely to utilize multiple services Finance -For providers, fee-for-service payment continue, but in a two-sided risk model they may need to pay back at the end of a contract period -For Medicare there have been savings, but thus far modest ACO in rural landscape -483 MSSPs Jan 2022 -430 Critical Access Hospitals participate; 1,643 RHCs -Where are the beneficiaries who are attributed to ACOs (more than 11 million as of Jan 22) Future of ACOs Now labeled pathway to performance -Require to accept risk no later than end of year 2 of participation -Increased "downside" risk comes wiht increases in the sharing the "upside" return -Still anticipating transition to other payment design -Quality Payment Program: 5% participation bonus for ACOs with downside risk Telemedicine -Healing at a distance -The use of teleccommunication and information technologies to provide healthcare services at a distance Telehealth modalities -Store and forward -Mobile health (mHealth) -Remote monitoring -Video conferencing -Direct patient-to-provider interaction (TeleDoc, TeleTriage) -Telehealth monitoring patient health activities (home health, health buddy) -Telehealth in inpatient settings (teleICU, teleIntensivist) -Telehealth in ER (teleStroke, teleTrauma, teleED) CAHs -Critical access hospitals -Medicare designation for small, rural hospitals with 25 or fewer beds that provide emergency medical services in addition to short-term hospitalization for patients with noncomplex health care needs. CAHs receive cost-plus reimbursement -More CAHs in Iowa than larger hospitals *MUST MEET ONE OF THE FOLLOWING CRITERIA* 1) Over 35 mile distance from another hospital 2) 15 miles from another hospital in mountainous terrain or areas wtih only secondary roads 3) 25 or fewer acute beds 4) Must limit average length of stay to 96 hours 5) MUST HAVE 24/7 EMERGENCY DEPARTMENT SERVICES -Approximately 1,349 certified CAHs throughout US- 1/4 of community hospitals Balanced Budget Act of 1997 Authorized outpatient Medicare reimbursement (Medicare+Choice program, renamed to Medicare Advantage) to support these cost-saving measures. Healthcare disparities in rural settings -Rural residents are older and poorer than urban counterparts -Higher rates of chronic illness and overall poor health -1/3 of all motor vehicle accidents occur in rural areas; 2/3 of deaths attributed to these accidents occur on rural rods -Twice as likely to die from unintentional injuries -Alcohol abuse = sig prob among rural youth -Meth use and admission treatment rates are higher in rural, non-metro areas -Suicide rates among rural males are significantly higher than in urban areas and the suicide rates among rural women are rapidly catching up to that of men -Rural communities = 20% of US population but less than 10% of physicians practice in rural communities -Rural residents less like to have employer-provided healthcare coverage or prescription drug coverage -Rural poor folx less likely to be covered by Medicaid benefits -Fewer dentists in rural areas -Majority of first EMS responders = volunteers -Have to travel long distances to receive healthcare Benefits of telemedicine -Improve access to clinical and specialist services -Reduces travel time and costs for both patients and providers -Timely decision-making, delivering best outcome possible -Improve management of chronic diseases -Expands the use of inter-professional teams to enhance patient care -Decrease incidence of hospital readmissions -Early warning system to care providers thus mobilizing care more rapidly -Increase chances for prof dev and specialist services -Mentoring of direct care health professionals -Educaiotnal tool for remote locations in contact with larger hubs Licensure Clinicians must be licensed in every state they practice; presents sig barrier to telemedicine expansion, thus, half of hubs provide services only within their state -An approach to decrease licensure burden is multi-state compacts/agreements Credentialiing Must occur before practitioner may provide services in a hospital -Once evaluated and verified, hospital engages in privileging process (access practitioner's competence in specific area of care) -Telehealth providers must also go through credentialing and privileging processes for the distantly located institution -Lengthy and expensive process, esp for small hospitals -There are the privileging by proxy standards that can be used Medicare & Medicaid Reimbursement -Medicare only reimburses for specific services when delivered LIVE VIDEO. Store and forward not covered/permitted for Medicare. -Patient's location at time of service = originating site. -Medicare uses telehealth almost exclusively as a tool for rural areas, and has narrowly restricted the geographic areas that are eligible to use telehealth -Medicare limits types of healthcare facilities who can provide telehealth delivered services -Medicare limits the types of healthcare professionals who can provide telehealth delivered services