PAINFUL/PAINLESS COST CONTROL
Health care costs rising, AcA says >50 employees must offer coverage Control via: utilization review, HMO, ACO, more OOP expenses Health care costs->outcomes, painless solutions to control costs
0.
B
Health outcomes
Health care costs
USA: flatter curve (MRI), cost containment may be painful, HMO -> stagnation A to B: expensive/better outcome, C: better outcome same cost (reduce unnecessary expenses)
to other factors, include only formal costs and not memberships/subscriptions Cost = price x qty, changes in factors different for pt/insurance/provider Cost control: controlling price inflation (reduce supply costs/formularies/salaries/high-end), eliminate inappropriate care (wrong procedure, industry influence vs efficacy, quality/outcome not necessarily better with more intensive services) and administrative waste (non-clinical costs, insurance marketing, billing, utilization review, quality assurance), innovation and cost savings (outpt infusions, day surgery w/o admittance, lower cost meds), prevention, analysis of cost effectiveness (may discriminate against disabled, restrictions)
MECHANISMS FOR CONTROLLING COSTS
Drivers of costs: utilization, inefficient payment, high prices/admin cost, medical liability Rate of spending exceeds economic growth -> unfair/inaccessible care Payers pay premium to health plan who makes payment to providers Regulatory strategies: laws, Medicare A, AcA; competitive strategies: if multiple insurance companies, people will seek cheapest, plans compete for business, price low HMO < PPO < FFS for employer care options, employee/employer both pay, employer payments towards premium, cost of insurance not lost wages, federal tax exemption increases employer value/employee savings, coBRA includes portion paid by employees, and employer plus ffifl; however financing controls produce decreased flow on payment side (insurers raise premiums if they can't control what they pay to hospital)
Price controls: set reimbursement rates like Medicare, uniform FFS schedule, predetermine pricing, competitive bidding between plans (reference pricing), cost shifting: charge to other payers increase to offset low cost of one payer, avoided using uniform FFS schedules; pt churning: higher use of service to offset lower price, like when providers don't often accept Medicaid -> low quality Utilization controls: contain use of health service by customers: changing unit of payment (rewards cheap care/fewer services but inhibits complex/multiple disorder care); pt behavior (cost sharing at sale to discourage pt demand for service, reduces cost, little effect on most costly/extremely ill, donut hole pts less likely to purchase expensive meds) Utilization management: deny payment for unnecessary services Supply limits: # caregivers, supplier induced demanded = more surgeons = more surgery
MEDICARE
Pharmacy outreach program: free info/referral to help MA residents adhere, help w plans, consult, community service at MCPHS A: hospital insurance, all drugs during inpt stay, symptom/pain during hospice, not chronic B: outpt, preventative, labs, screenings, premium depends on income, outpt drug limited (injectible/infusible as part of visit, nebulized solns/infusion pump meds, oral cancer/nausea, pump insulin, diabetes test supplies, flu/pneumonia vaccines), injury meds C: medicare advantage, private insurance contract w medicare, another way to get ABD coverage, hospital/medical/drug/vision/dental/hearing possible benefits D: private insurance contract w medicare, on location, voluntary outpt drug coverage for
brand/generics, biologics, insulin/supplies, cover ffi drugs in each category, protected: antidepressants/antipsychotics/anticonvulsants/anticancer/immunosuppressants/HIVAIDS vaccines zoster Zostavax/Shingrix, DTP, Hep B