Chapter 10: Private Health Insurance Market
Opportunities for Practioners
1. Demonstrate value 2. Demonstrate links between outcomes and care coordination 3. Become involved with the design and implementation of health information technology. 4.Employment opportunities
Health care Prior to 1920
1. Distrust in hospital care due to increased mortality rates 2. Treatment occurred in home by families and physicians. 3. increased use of technology such as X-ray, BP monitoring, and identification of disease increased trust in hospitals 4. Increased healthcare cost due to more treatment in hospitals
Health Insurance Plans
150 million rely on employers or Marketplace for health benefits Indemnity Insurance HMO PPO POS
Origin of Blue Cross
1938 Blue Cross Commission of the American Hospital Association began a formal approval process for plans.
Addition of new Private Insurance Companies
A direct result of the success of Blue Cross and Blue Shield.
ACA and Impact on Cost
ACA has reduced the overall cost of insurance and increased coverage. Expands coverage to those who are healthy and those who are not. Caused financial strain on the insurance companies but this is starting to stabilize as they recover.
Health Insurance Portability and Accountability Act (HIPAA)
An amendment to ERISA to protect workers and their families with pre-existing conditions. Allows individuals to continue health insurance after change or loss of job. Privacy and Protection of Personally Identifiable Information and Protected Health Information
Private Insurers Initiatives
Change from insurance carriers to consumer health solutions companies. Use of accountable care organizations (ACOs). Increase use of technology.
Health Insurance Exchange Marketplace
Created under the ACA, Gives people who are not offered employer-sponsored plans a place to compare and buy insurance plans. Individuals pay the full cost of the premium through the market place.
Health Maintenance Organization (HMO) origin
Developed in 1930s. An alternative way of organizing and financing healthcare delivery.
Federal Laws Impacting Insurance
ERISA HIPAA ACA
ACA and Employers
Employers must offer insurance benefits to FULL_ TIME employees or be subjected to penalties. Small business owners are not subject to penalties. They are given tax credits to provide insurance under the Small Business Health Options Program.
Massachusetts Health Insurance of Boston
First group plans in 1847
Health Saving Account
Formed in 2003. Has to be linked to a high-deductible plan. The employee and employer can make contributions to the account. The remaining amount rolls over each year.
Not Grandfathered in Plans
Groups plans that exclude those with pre-existing conditions.
Employer-Sponsored Health Insurance
Health Insurance Plans bought through the employer. The employer pays the bulk of the premium and the employee pays the rest. Increased cost mean increased premium for the employee. Larger companies will sometimes Self-Insure to cut cost. They make deals with the providers and set aside funds for health benefits.
Health Maintenance Organization (HMO)
Healthcare delivery and financing are integrated under managed care. No out-of-network coverage excepts in emergency. Emphasis is on preventative health and quality assurance.
Preferred Provider Organization (PPO)
Hybrid insurance policy with indemnity and managed care. discounted rates for in-network, limited coverage for out-of-network. Out of pocket deductible.
Point of Service Plan (POS)
Hybrid policy. Costumer chooses the provider without PCP authorization however in-net-work only still applies.
Reimbursement Tied to Outcomes
Increased patient outcomes leads to increased reimbursement rates for quality interventions.
Health Reform and Private Insurers
Increases consumer protections from high premiums, limited access to coverage, and poor communication.
Health Reimbursement Arrangement (HRA)
Money can only be used for medical expenses. Only employers can make contributions. Excess funds roll over each year. It does not have to be tied to a high-deductible plan.
Consumer Driven Health Plans (CDHP)
More Recent. Empowers the consumer to make decisions about their coverage. Hybrid plan of high-deductible health plan with a pre-tax savings plan. Puts the consumer at risk so they will make more cost effective decisions.
Legislative Changes
Movement for Repeal and Replace from Republicans.
Indemnity Insurance
One fixed cash payment toward a particular medical expense.
High Deductible Health Plan (HDHP)
Plan with lower premium, high deductibles, co-insurance, and out of pocket max that the consumer must pay before receiving services.
Private Insurance and the Marketplace
Private Insurers can sell on the marketplace but must offer 4 tiers from lowest to highest premium. They must meet the minimum requirements set by ACA
Laws and Regulations Impacting Health Insurance
Regulation is primarily the responsibility of the state due to 1945 McCaran-Ferguson Act. Self-Insured plans are not held to state requirement.
Affordable Care Act (ACA)
Restructured private insurance Set minimum standards for health coverage Provides assistance to small businesses and individuals in certain circumstances. Individual Mandate: all Americans are required to have health insurance.
Employee Retirement Income Security Act (ERISA)
Sets minimum standards for employer-sponsored benefits including Self-Insured Companies. Exempts Self-Insured companies for state regulations.
Flexible Saving Account
The account is used for out-of-pocket medical expenses Employees and employers can contribute to the account. Excess funds do not roll over and it does not have to be tied to a high-deductible plan.
Quality Patient Care and Care Coordination
Transition Care Model: attributes positive outcomes with access, quality, and cost. Transitional Care Nurse: Continuity of care from hospital PCP.
Civil War Time
When the first insurance plans became available
1980s
increased strategies for providing access, controlling cost, avoiding national health insurance
