1
Q
3 Managed Care Principles
A
1) limited access to the universe of providers
2) payment mechanisms that reward efficiency
3) enhanced quality control procedures
2
Q
Which of the 3 Managed Care Principles is described below:
-panel of health care providers that are contracted with or employed by the MCO
-Limiting the providers creates competition in areas of heavy MCO concentration
Panels can be opened or closed
- Panels go through a credentialing process that reviews:
- Authorization of services = often primary care physicians serve as gatekeepers
A
limited access to the universe of providers
3
Q
Which of the 3 Managed Care Principles is described below:
- Providers are reimbursed for their services through a variety of ways.
- Provider assumes either some or all of the financial risk
A
payment mechanisms that reward efficiency
4
Q
Which of the 3 Managed Care Principles is described below:
- MCOs perform utilization review, clinical pathways, benchmarking, and case management functions
- Case managers = coordinate all aspects of patient care
- Therapy benefit managers = intermediary between the patient/therapist and insurer/MCO. Evaluate the appropriateness of therapy. Employed by companies that contract with MCOs.
A
enhanced quality control procedures
5
Q
What’s Discounted fee schedule?
A
providers accept a contract that is less than the full charge for certain services.
6
Q
What’s Bundle Payment System ?
A
the insurer begins to limit financial risk. This is done by paying one fee to the provider for a set of patient services.
7
Q
What’s Capitation
A
completely separates payment from treatment incidence. Capitation prospectively pays the provider a predetermined sum for each covered member of the plan on a regular basis (usually monthly)
8
Q
What managed care products is described below:
- Contract between providers and purchasers of health care/MCOs
- Plans use pre approval, utilization review, and discounted reimbursement
- Providers have an increased pool of patients, low financial investment, and more autonomy
- Beneficiaries have a choice of providers within the panel
A
Preferred Provider Organizations (PPO)
9
Q
What managed care products is described below:
•highly aggregated form of managed care
- Utilize gatekeepers/physicians to pre-approve
- Utilization review to control costs
- Beneficiaries access with pre-approval only, from only those providers in panel
- Provider payment varies = fee for services, case based, and capitation.
A
Health Maintenance Organizations (HMO)
10
Q
What managed care products is described below:
•Hybrid plan containing both HMO and PPO forms of managed care
- Beneficiaries chose provider at time of service
- Benefits paid at a higher percentage within primary care/HMO provider rather than others in panel/PPO
- Rules are based on which option patient chooses
A
Point of Service
11
Q
What managed care products is described below:
- Often used with PPO models
- Allow individuals greater control over health care utilization and spending
- To discourage overuse of services many require co-payments
- Health Savings Accounts (HSAs) often used with high deductible health plans (HDHP) can also discourage overuse of services
A
Consumer-Directed Health Plans
12
Q
What are the different managed care products?
A
PPO
HMO
Point of service
consumer directed health plans
13
Q
What are the 4 models of how provider contracts?
A
Staff model, group model, network model, and independent practice associations
14
Q
Which of the 4 models of how provider contracts are established is described below?
•Providers are employed by the HMO and receive a salary
Some may provide incentives based on performance
Example: Kaiser in CA, salaries therapists and physicians, owns the hospitals
A
Staff model
15
Q
Which of the 4 models of how provider contracts are established is described below?
▫Contract with multidisciplinary provider group practices
▫Some are captive groups
▫Non-exclusive relationship/independent group
▫Commonly seen in large multispecialty practices
A
Group Model
16
Q
Which of the 4 models of how provider contracts are established is described below?
▫HMO contracts with multiple provider group practices, both primary and specialty
▫Similar to group model but greater geographical coverage, less integrated
A
Network model
17
Q
Which of the 4 models of how provider contracts are established is described below?
- contract with individual providers or small provider groups
- HMO contracts with ___ to provider services to those in the HMO
- Providers keep individual and group practices and see patients from multiple HMOs
- Most commonly used by private practice OTs and PTs
A
IPA (Independent Practice Associations)
18
Q
What may be some risks of this Staff model?
A
Beneficiaries receive coverage at a fixed price per month but must be treated within HMO = highly integrated
19
Q
Medicare Eligibility Program eligibility is primarily determined by meeting the criteria of…?
A
Medicare Part A
20
Q
Who is eligible for Medicare A?
A
- Anyone 65 years of older
- have contributed for 10 years (40 quarters)
- if no contribution can pay a monthly premium to obtain benefits
21
Q
Anyone who is eligible for Medicare A is eligible for…?
A
Medicare B/C/D
22
Q
Which medicare plan covers these services:
inpatient hospital stays, SNF, hospice, and home health care
-short rehab
A
Medicare Part A
23
Q
Which medicare plan covers these services:
supplemental medical insurance
-professional services, outpatient, home health, DMF, prosthetics, orthotics
A
Medicare Part B
24
Q
Which medicare plan covers these services: hospital care, doctor visits, and other medical services
- provided all benefits by Medicare Parts A and B but not hospice care
- prescription drug, dental and eye care
A
Medicare Part C
25
Which medicare plan covers these services: provides outpatient prescription drug coverage
Medicare Part D
26
Each resident is assessed using the______
there's 3 parts:
Minimum Data Set (MDS)
Comprehensive description of the status and problems of the resident
The care areas assessment
Is triggered when there is a change in the MDS
Structured process by the care team to identify, analyze, address the problem
RAI (Resident Assessment Instrument)
27
What system is described below:
Reimbursement method that determines what services will be covered and how much will be paid for the services before
they are delivered
Resource utilization group (RUG) is the _____ system used for patients in under Medicare part A.
PPS = Perspective Payment System (1998, Newest version 2011)
28
What are the RUG (Resource utilization group) categories?
Ultra High Rehabilitation plus extensive services
Very High Rehabilitation plus extensive services
High Rehabilitation plus extensive services
Medium Rehabilitation plus extensive services
Low Rehabilitation plus extensive services
29
What payment model is described below:
Coming this October!
Use ICD-10 diagnosis and procedural codes in order to classify SNF residents into one of ten ____ Clinical Categories
Then the patient would be further classified
The idea is to provide a connection between the ICD-10 codes, the procedure codes, and the 10 ____ clinical categories
PATIENT DRIVEN PAYMENT
| MODEL (PDPM)
30
Define Fraud
making false statements or representations of material facts to obtain benefit or payment
31
Define Abuse
any practice that is not consistent with the goals of providing pt with services that are medically necessary, meet professional standards, and are fairly priced
32
OMRA
Other medicare required assessments (OMRA)
3 types: to therapy services that are components of the RAI. These therapy intensity assessments are used to gather information for proper placement of patients into payment groups
33
Levels of Fraud and Abuse: Level 1
reviews the utilization pattern against a standard “edit”
34
Levels of Fraud and Abuse:
| Level 2
a focused review by health professionals, review documentation to determine if care meets Medicare guidelines
May result in denial or referral to level III
35
Levels of Fraud and Abuse:
| Level 3
onsite review of patient documentation and billing records
36
Which medicare part A benefit is described below:
Require the skills of qualified technical or professional health personnel
Must be provided directly by or under the general supervision of these skilled rehabilitation personnel
Must be provided on a daily basis with need met with inpatient care with a least 5 days a week
Services must be ordered by a physician.
SKILLED SERVICES
37
Which medicare part A benefit is described below:
Qualify based on home confinement and need for skilled services (rehab or nursing)
MD must confirm homebound
Can be Med A or Med B
Med A
All evaluated using OASIS (Outcome and Assessment Information Set)
Hospice
Home health agency prospective payment
HOME HEALTH CARE BENEFITS
38
Which medicare part A benefit is described below:
Rehabilitation hospital setting
Patients must need 3 hrs of therapy 5 days a week to qualify = “three hour rule”
“The 60% rule” = at least 60% of patients must be from certain patient diagnostic categories
Evaluated using the Inpatient Rehabilitation Facility-Patient Assessment Instrument (IRF-PAI)
Inpatient rehab prospective payment
INPATIENT REHAB FACILITY BENEFITS
39
Which medicare part A benefit is described below:
couldn't find in ppt
Hospital
40
PPACA’s impact on Medicaid
The PPACA 2010 expanded Medicaid eligibility to all persons up to 133% federal poverty level (FPL)
This change would make single men and childless couples (who have not been eligible to date) eligible for Medicaid
41
Eligibility requirements for Medicaid
1) children
2) adults: pregnant women, persons with disabilities, or low income persons over age of 65
3) Persons receiving SSI (Social security Income) qualify for Medicaid
4) Low income Medicare beneficiaries qualify for Medicaid
42
Mandatory benefits of Medicaid
- Inpatient and outpatient hospital services
- Laboratory and radiology services
- Certified pediatric and family nurse practitioners
- Nursing facility services for age 21 or over
- Early and periodic screening, diagnosis, and treatment (EPSDT) services under age 21
- Family planning services and supplies
- Physicians’ services
- Home health care for persons eligible for nursing facility services
- Pregnancy-related services (e.g. nurse-midwife services 60 days postpartum care)
- Transportation to medical care
- Tobacco cessation programs
43
Optional
| benefits of Medicaid
Prescription drugs
Rehabilitation therapies including OT and PT
Prosthetics and orthotics
Personal care attendants
44
What are the Veteran Affairs eligibility criteria?
Minimum of 2 years of service and an honorable discharge from the military
Veterans with service related injury or disability are given highest enrollment priority
Impoverished veterans also receive priority enrollment in the VA
Non-service connected veterans have to meet income/asset requirements or pay deductibles and copays
45
Describe TRICARE
- For active military personnel 2019
- Also for retired military and members of their families
- Criteria for coverage of OT and PT that is “medically necessary and considered proven”
46
Describe Indian Heath Services (IHS)
- Agency of the federal government to provide health care to American Indian/Alaskan Natives
- Direct delivery by the Indian Health Service
- Health care developed and administered by the tribes (Tribal self determination)
- Both use a global budgeting system
- Resources come from direct appropriations by the Congress
47
What are the 3 types of HOSPITAL CHARACTERISTICS: OWNERSHIP
1) Not-for-profit = hospitals operated by nonprofit organizations
2) Owned and operated by for profit corporations = investor-owned or for-profit hospitals
3) Owned and managed by federal, state, or local governments = public hospitals
48
Level of Acute care
| Primary:
1st level of care in the US health care system
Main entry point
Illnesses are general, episodic, common, and non chronic in nature
1995 Institute of Medicine defined primary care
“Primary care is the provision of integrated, accessible health care services by clinicians who are accountable for addressing a large majority of personal health care needs, developing a sustained partnership with patients, and practicing in the context of family and community”
49
Level of Acute care
| secondary:
Can be provided in an ambulatory or inpatient basis
More intense and often over a longer period of time than primary
Chronic conditions requiring continuous care
50
Level of Acute care
| tertiary :
Highly specialized, complex, costly, delivered in an inpatient sett
51
Level of Acute care
| quaternary:
Predominantly provided in academic medical centers
52
Article: Occupational therapy practice in acute physical hospital settings
“Why didn’t someone explain this to me at the doctor’s office? I would have done it if I had just understood better”
-OTs proposed role in primary care (p.507 of article)
Assist physician by means of early intervention to prevent disease or disability
Provide holistic care focusing on symptoms impacting function
Improve patient satisfaction by addressing broad issues/concerns
Provide simple interventions that can be done at home
Suggest activity modification or adaptive equipment/technology
Provide group education or intervention sessions
Affordable Care Act (ACA) brought changes related to primary care
Accountable care organizations (ACOs)
Patient centered medical home (PCMH)
53
4 themes describes in Article: Occupational therapy practice in acute physical hospital settings
1) Comparing the practice of novice and experienced OTs in acute care
Novice note the importance of quality supervision as essential, but often feel they do not get it
2) OTs and the discharge planning process
3) Role of occupation in acute care setting
4) personal skills needed and organization factors affecting acute care practice
Relationships with multidisciplinary colleagues are both valuable and a source of frustration
*know the findings of each theme*
54
Which theme is describe below from Article: Occupational therapy practice in acute physical hospital settings
- Clinical support for novice therapists was found to be essential in assisting skill development in this area.
- importance of quality supervision being essential for the retention of new grad OTs.
- Role incompatibility was identified as being of concern to novice therapists in the acute setting.
(1) Comparisons between the practice of novice and experienced occupational therapists in acute care.
55
Which theme is describe below from Article: Occupational therapy practice in acute physical hospital settings:
- practices were predominantly defined by their ability to provide a safe and timely discharge home for patients.
- perceptions of risk associated with discharge played an important part in the decision-making process for acute care OTs
- High levels of perceived risks with regard to either safety to self or others were found to negatively affect clients’ ability to be discharged to their pre-admission environment.
(2) Occupational therapists and the discharge planning process.
56
Which theme is describe below from Article: Occupational therapy practice in acute physical hospital settings:
-Even though acute care settings largely follow a medical model, we can still incorporate client-centered, occupation-based interventions into our treatments.
(3) Role of occupation in the acute care setting
57
Which theme is describe below from Article: Occupational therapy practice in acute physical hospital settings:
- Effective time management skills were congruent with having strong clinical reasoning and decision-making skills
- requirement when considering the risks associated with facilitating rapid and timely hospital discharges.
- access to adequate supervision with a senior OT was strongly valued by novice therapists and was ranked as a highly valued resource in numerous studies.
(4) Personal skills needed and organization factors affecting acute care practice.
58
What's Formal care
begins with services to supplement the family (home health care), extends to services
that replace informal (SNF).
59
What's Informal care?
Informal care =consists of the care provided by the family
60
What are the types of formal care?
Nonresidential and Residential
61
What type of formal care is described below?
- Informal care is supported and supplemented with targeted interventions based on client and caregiver needs
- Home health agencies, hospice, and adult day services
Nonresidential
62
What type of formal care is described below?
- Provides a place to live along with services, Replace informal care systems
- Both provide skilled and non-skilled services
- Important to understand the extent of services and needs of patients for appropriate referrals and discharges
Residential
63
Nonresidential Formal Care: Home Health Care
What is home health care?
Formal, regulated program of care offering medical, therapeutic, and non medical services by a variety of professionals in the patient’s home
Patients are medically stable but unable to access other community resources
64
Nonresidential Formal Care: Hospice
Services for those with terminal illness and their support system/ family during and after the dying process
First Hospice in the US was New Haven CT in 1974
65
Residential Formal Care: Assisted Living
Provides housing and support services to those who cannot live independently but generally do not require a skilled level of care
Ideal for those who need supervision or non-skilled services on a regular basis
66
Residential Formal Care: Skilled Nursing Facilities
-Serve two types of residents: Post-Acute & Chronic
Services: skilled care, assistance with at least 3 ADLs, 3/4th have cognitive problems, complex needs but are often medically stable
- 4 basic services: nursing and rehabilitation, personal care, residential services, and medical care (24 hour care)
- OT/PT provides evaluations and interventions
- Concerns regarding quality of care in SNFs:
67
Subacute Care: Inpatient Rehab Facilities (IRFs)
-Independent, stand-alone, or dedicated unit in hospital fixed rate
-Provide care in preparation to return to the community
Often treat most complex patients: TBI, SCI
- Pts need to tolerate 3 hours of therapy a day (Medicare guidelines)
- Services: PT, OT, SLP, recreation therapy, nursing, counseling, psychiatry
68
Subacute Care
- Comprehensive inpatient care for those with acute illness/injury/exacerbation
- After or instead of acute hospitalization to provide medically complex treatments
- Step down from acute hospitalization intended for short term recuperation
- Can be found in SNF or hospitals
- Lower intensity of RN and physician care
- OT/PT daily but less than 3 hours a day
69
Article: Coming to Terms with the IMPACT act of 2014 (DeJong, 2016)
-Act focuses on the development and implementation of post-acute quality measures with a specific timetable for each of the 4 post-acute settings
-Changes in health care
Gradual move from fee for service to bundled fee
-Move away from prestige and risk and move towards price and quality of care
This will require 2 sets of reforms:
1) pricing and payment reforms
2) quality and outcome metrics
ACA makes Medicare place of transformation of delivery and finance
IMPACT focuses on quality metric track, secondarily on the payment reform, picks up where ACA leaves off
70
Article: Coming to Terms with the IMPACT act of 2014
| what are the 3 report types?
1) Patient Assessment Data
All post-acute providers must report data from the following CARE item set domains:
1) diagnoses including comorbidities, 2) impairments, 3) functional status, 4) cognitive function and mental status, 5) services and treatment required
2) Quality Measures
Required to report 5 sets of quality data
1) physical and cognitive function and changes in function, 2) skin integrity, 3) medication reconciliation, 4) incidence of major falls, 5) discharge planning
3) Resource Use Measures
Required to report 3 main measures
1) total Medicare spending per beneficiary, 2) whether patient was discharged to the community 3) all-cause risk-adjusted preventable hospital readmission rates
71
**Final Jeopardy**
The following illustrates this form of Post-Acute care: John has Cancer and has been given a prognosis of 3 months. He has begun to receive services for his terminal illness including pain management and emotional counseling while his family is also supported.
Non-residential formal care: Hospice
72
Requirements for Individualized Education Program (IEP)
* A statement of the child’s present level of educational performance and how disability affects participation in the curriculum.
* Measurable annual goals.
* A statement of special education and related services, and supplementary aids and services to be provided for the child.
* A statement of the extent, if any, to which the child will not participate with children without disabilities in the regular classroom.
* A statement of any modifications in the administration of state- or district-wide assessments of student achievement or an explanation of why the assessment is not appropriate for the child and an alternative assessment measure.
* Projected date for initiating services.
* Statement on how student progress towards measurable goals will be assessed, how the parent(s) will be informed of progress on a regular basis, and the extent to which progress is sufficient to allow the child to achieve goals by the end of the school year.
73
What is Child Find?
- “Each state must have a comprehensive system of Child Find in order to identify, locate, and evaluate children with disabilities residing in each state who are in need of special education and related services”
- May have been identified and receiving EI through IDEA part C
74
What Mental Health Practice Settings: Traditional is described below:
- Utilized for persons in crisis, acute symptoms, danger to themselves or others
- Inpatient unit goal - provide safe and structured environment to manage issues of inability to care for self, danger to self and others, and/ or deterioration in condition
Acute and subacute hospitalization
75
What Mental Health Practice Settings: Traditional is described below:
Originally for those in need of the most intensive MH care
Maybe unable to live in community due to safety concerns or committed by the court
LTG - provide stabilization with reintegration into the community
Long-term hospitalization
76
What Mental Health Practice Settings: Traditional is described below:
Provides a structured program for those 1) ready for discharge from inpatient but still require high level of support 2) high risk of re-hospitalization
-Person attends an individualized program for day, evenings, weekends. Remain in the community, return to work.
Partial hospitalization
77
What Mental Health Practice Settings: Traditional is described below:
For those struggling in the early stages of crisis
- Immediate, short term, individualized treatment to minimize the crisis and deter hospitalization
- Overnight residential care, 24/7
Crisis stabilization
78
What Mental Health Practice Settings: Community Based is described below:
- Comprehensive services to severely mentally ill and children, families, and adults suffering from stress
- Cores services - outpatient services, 24 hr emergency care, day treatment/ partial hospitalization, screening for long term psych
- To be eligible for Medicare must treat at least 40% who are not eligible for Medicare benefits
Community mental health centers CMHC
79
What Mental Health Practice Settings: Community Based is described below:
- Comprehensive, intensive, individual, coordinated, structured services
- Goal is to address social, educational, and leisure needs of participants by promotion g daily routines and a sense of belonging
- Open at least 5 days a week, some evening and weekends outings
Day rehab programs
80
What Mental Health Practice Settings: Community Based is described below:
-Provide services during the day to provide structure to increase quality of life and health status of those 65 and older
Adult day services
81
What Mental Health Practice Settings: Community Based is described below:
- Similar to day rehab programs but they also provide support and structure to meet vocational needs
- Individuals are members with a focus on work, work order day, members and staff work side by side
- Typically open 8 hrs a day, 5 days a week, and evenings and weekends
- Transitional and Supported Employment
Clubhouse model
82
What Mental Health Practice Settings: Community Based is described below:
-Comprehensive, flexible, community based treatment support, 24/7/365
-Multidisciplinary team –
Participants are diagnosed with severe and persistent mental illness, hx of difficulty being safe, difficulty with ADLs and IADLs
- Case management, initial and ongoing assessment, psych services, employment, housing, family support, and education
- Effective for those with a hx of multiple hospitalizations and co-occurring substance abuse
Programs of assertive community treatment PACT
83
What Mental Health Practice Settings: Community Based is described below:
- Consumers provide services and structure for other consumers
- Drop in centers - meet social and leisure needs
- May be referred out if need more intensive support
Consumer Operated Services
84
Understand and differentiate between each country: Canada
-Canada provides universal access to health care
1) Administration of the provincial insurance must be carried out by an accountable public authority
2) All necessary services, including physicians and hospital services, must be insured
3) All insured residents must be able to receive the same level of care
4) The residents who move to different provinces must retain their home province insurance for a minimum grade period
5) There must be reasonable access to health care services
*Funding comes from federal & provincial taxes on both personal & corporate income*
85
Understand and differentiate between each country: United Kingdom
- a centralized, single payer system funded by general revenue from national taxes
- Cover preventative services, physician services, hospital care, prescription meds, and some long-term rehab.
-Funding:
Patients can purchase private insurance that allows them to “hop” over the lines
-NHS employs general practitioners, nurses, ambulance staff, and other health care workers to provide covered services
86
Understand and differentiate between each country: Germany
- 1883 First nation to enact compulsory health insurance
- Required employers and employees to pay into sickness funds designed to pay for medical expenses of employees
- The revised Statutory Health Insurance (SHI) covers 85% of the population, 10% by private insurance
-SHI has 150 funds that are autonomous, non profit, & non governmental entities regulated by law
Payment of services
87
Understand and differentiate between each country: France
- Universal coverage system that covers all residents, publicly finances through the Statutory Health Insurance (SHI)
- Covers limited services
- Cost sharing that includes co-insurance, co-payments, and extra billing
- SHI is finances primarily through employer and employee payroll taxes and national income tax
- Funds managed by a board that has representatives from employers and employees
- Strong push in recent years to have a gatekeeper and more than 85% of the population has registered with a primary care physician
88
Understand and differentiate between each country: United States
- Fragmented health care system funded by a mix of private and public sources
- The system has a large number of uninsured and many underinsured
- Covered benefits vary by type of insurance. Often include physician and hospital services, preventive services, physiotherapy, mental health, and prescription drugs
- Finances by individuals or tax-free premium contributions shared by employers
89
What Performance of health care systems is described below:
- The lack of universal coverage in the US impacts access to health care
- US is fundamentally funded by private insurance
- The Commonwealth Fund reported 54% of US citizens report problems with access to health care
- Although US as financial barriers to access, they received relatively timely access to services
Access and Level of Expenditure
90
What Performance of health care systems is described below:
1) Effective care
2) Safe care
3) Coordinated care
4) Patient-centered care
US has positive findings for providing prevention and patient centered care but had lower scores for safe and coordinated care
Quality
91
What Performance of health care systems is described below:
- Defined as “... a health care system that maximizes the quality of care and outcomes given the committed resources as well as ensuring that additional investments yield a net value” (p. 235)
- US was last on overall efficiency: measures of timely access to records and test results, duplicative services, re-hospitalization, and physicians use of health information technologies
Efficiency
92
What Performance of health care systems is described below:
- Hard to measure across countries due to cultural norms
- US invests a large amount into health care yet does not have the outcomes
- 29% of US said system works well compared to 38% in Canada and Germany
- 27% of US felt the health care system needed complete rebuild
Satisfaction
93
Public health goals: What are they, what do they look like in action?
Goal is to
- preserve health
- minimize the impact of morbidity
- Accomplished through prevention, lifestyle changes, reducing errors/waste, closing disparity gaps, and improving accountability and coordination of care
94
What is described:
when hospitals and physicians join with other organizations to provide a continuum of care within a single organization, including therapy services, nursing home care, health plans, etc.
Refers to combination of two or more firms that were previously separate and whose products or services are inputs/outputs from the production of another service into a single firm. Physician-hospital organizations (PHOs) are most common type.
Vertical integration
95
What is described:
when two or more firms producing similar services join to become a single organization - hospitals merging and consolidation of smaller solo practices into larger multispecialty group practices
Horizontal integration
96
What is described: Structural mechanism that facilitates the integration of physicians into the management and governance of the hospital as well as the integration of management into the activities of the clinical-medical staff.
Purpose is to link patient entry points to the health care delivery system, forming a continuum of services for the patient. Physician groups are forging closer ties with hospitals as a means of lowering expenses and taking advantage of managed care contracting opportunities
Physician-hospital relationship
OTB 508
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