HCMG 2500 Final Exam 100% Correct!!
Payment Models and their Incentives - ANSWERS· Salary = do as little as possible for
as few as people as possible
· Capitation = od as little as possible for as many people as possible
· FFS = do as many tasks as possible
· P4P = do as many compensated tasks as possible
Accountable care organizations (ACOs) - ANSWERSgroup of hospitals and providers
who come together to take on a population-based payment model and sign contract
with insurance company
Key Attributes of ACOs: - ANSWERS· Incentivizes care coordination across different
providers
· Incentivize cost savings through shared savings
· Ensure minimum quality
· Voluntary participation
· Focused on chronic and primary care
Describe trend of ACOs - ANSWERSskyrocketed in the 2010s but are currently in a
plateau
30 million people are under an ACO
Describe the savings related to ACOs - ANSWERSmodest but increase over time
Describe the impact of quality related to ACOs - ANSWERSquality benchmark
increased
Improve ACO efficiency: - ANSWERS· Investment in case management outside of
hospitals
· Focus on post-discharge planning
· Avoid hospitalization in the first place
Bundled Payment - ANSWERSpayment for comprehensive, coordinated intervention via
a single payment based on an episode of care
Improve bundled payment efficiency: - ANSWERS· Avoid post-acute care facilities
· Avoid readmissions
Hospital practice changes: - ANSWERS· Reduce skilled nursing facility referrals
· Risk stratifying patients and pre-hab
· Strengthen home supports and home health care agencies
· SNF selection (networks0, integration, and coordination
, Issues to consider with APMs: - ANSWERS· Identifying and setting optimal benchmarks
· Determining risk-adjustment
· Integrating equity within APM design
Players of the Payer Landscape: - ANSWERS· Nationals = for profit (ex: Anthem,
Cigna, Aetna, Humana, United)
· Blues/regionals = mostly not-for-profit
· Local payers
· Specialty payers (ex: Medicaid)
fully insured - ANSWERSinsurance company takes full risk of managing cost for a small
pool
self-insured - ANSWERSlarge pool --> employer bears risk or buys stop-loss insurance
and administers medical benefits via provider management and claims processing
payer's economics are driven by what - ANSWERSspread between medical costs +
administrative expenses and premiums + investment yields
Describe the trend of payer profit margins - ANSWERSincreased and trending upwards
Describe ACA enrollment - ANSWERSrisen to 14.5 million
Recent regulatory actions to facilitate growth and stabilize risk: - ANSWERS· Enrollment
continuing after encouraging policies made to counteract COVID-19
· State innovations (i.e., waivers, state-based exchanges)
· Additional enrollment flexibility (i.e., let employers make improvements to market plan)
· Plan standardization (i.e., CMS requiring carriers on federal market plans to offer
standardized plans)
Describe trends in Medicare - ANSWERSMedicare Advantage accounts for 1/3 of
enrollment and spending but has grown exponentially and plans have increased
efficiency
Medicare beneficiaries have more options and average prices have decreased as a %
of FFS
Describe trend of Medicaid spending - ANSWERSgrown over time
Is Medicaid enrollment expected to increase or decrease - ANSWERSdecrease (but it
has increased over the years)
Forces driving value-based care - ANSWERS· increase in chronic disease burden and
spending
· growth in government-covered lives
Payment Models and their Incentives - ANSWERS· Salary = do as little as possible for
as few as people as possible
· Capitation = od as little as possible for as many people as possible
· FFS = do as many tasks as possible
· P4P = do as many compensated tasks as possible
Accountable care organizations (ACOs) - ANSWERSgroup of hospitals and providers
who come together to take on a population-based payment model and sign contract
with insurance company
Key Attributes of ACOs: - ANSWERS· Incentivizes care coordination across different
providers
· Incentivize cost savings through shared savings
· Ensure minimum quality
· Voluntary participation
· Focused on chronic and primary care
Describe trend of ACOs - ANSWERSskyrocketed in the 2010s but are currently in a
plateau
30 million people are under an ACO
Describe the savings related to ACOs - ANSWERSmodest but increase over time
Describe the impact of quality related to ACOs - ANSWERSquality benchmark
increased
Improve ACO efficiency: - ANSWERS· Investment in case management outside of
hospitals
· Focus on post-discharge planning
· Avoid hospitalization in the first place
Bundled Payment - ANSWERSpayment for comprehensive, coordinated intervention via
a single payment based on an episode of care
Improve bundled payment efficiency: - ANSWERS· Avoid post-acute care facilities
· Avoid readmissions
Hospital practice changes: - ANSWERS· Reduce skilled nursing facility referrals
· Risk stratifying patients and pre-hab
· Strengthen home supports and home health care agencies
· SNF selection (networks0, integration, and coordination
, Issues to consider with APMs: - ANSWERS· Identifying and setting optimal benchmarks
· Determining risk-adjustment
· Integrating equity within APM design
Players of the Payer Landscape: - ANSWERS· Nationals = for profit (ex: Anthem,
Cigna, Aetna, Humana, United)
· Blues/regionals = mostly not-for-profit
· Local payers
· Specialty payers (ex: Medicaid)
fully insured - ANSWERSinsurance company takes full risk of managing cost for a small
pool
self-insured - ANSWERSlarge pool --> employer bears risk or buys stop-loss insurance
and administers medical benefits via provider management and claims processing
payer's economics are driven by what - ANSWERSspread between medical costs +
administrative expenses and premiums + investment yields
Describe the trend of payer profit margins - ANSWERSincreased and trending upwards
Describe ACA enrollment - ANSWERSrisen to 14.5 million
Recent regulatory actions to facilitate growth and stabilize risk: - ANSWERS· Enrollment
continuing after encouraging policies made to counteract COVID-19
· State innovations (i.e., waivers, state-based exchanges)
· Additional enrollment flexibility (i.e., let employers make improvements to market plan)
· Plan standardization (i.e., CMS requiring carriers on federal market plans to offer
standardized plans)
Describe trends in Medicare - ANSWERSMedicare Advantage accounts for 1/3 of
enrollment and spending but has grown exponentially and plans have increased
efficiency
Medicare beneficiaries have more options and average prices have decreased as a %
of FFS
Describe trend of Medicaid spending - ANSWERSgrown over time
Is Medicaid enrollment expected to increase or decrease - ANSWERSdecrease (but it
has increased over the years)
Forces driving value-based care - ANSWERS· increase in chronic disease burden and
spending
· growth in government-covered lives
