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The Health IT Workforce Curriculum was developed for U.S. community colleges to enhance workforce training programmes in health information technology. The curriculum consist of 20 courses of 3 credits each. Each course includes instructor manuals, learning objectives, syllabi, video lectures with accompanying transcripts and slides, exercises, and assessments. The materials were authored by Columbia University, Duke University, Johns Hopkins University, Oregon Health & Science University, and University of Alabama at Birmingham. The project was funded by the U.S. Office of the National Coordinator for Health Information Technology. All of the course materials are available under a Creative Commons Attribution Noncommercial ShareAlike (CC BY NC SA) License. The course description, learning objectives, author information, and other details may be found at http://archive.org/details/HealthITWorkforce-Comp01Unit04. The full collection may be browsed at http://knowledge.amia.org/onc-ntdc or at http://www.merlot.org/merlot/viewPortfolio.htm?id=842513.
Titolo originale
01-04D - Introduction to Healthcare and Public Health in the US - Unit 04 - Financing Healthcare Part 1 - Lecture D
The Health IT Workforce Curriculum was developed for U.S. community colleges to enhance workforce training programmes in health information technology. The curriculum consist of 20 courses of 3 credits each. Each course includes instructor manuals, learning objectives, syllabi, video lectures with accompanying transcripts and slides, exercises, and assessments. The materials were authored by Columbia University, Duke University, Johns Hopkins University, Oregon Health & Science University, and University of Alabama at Birmingham. The project was funded by the U.S. Office of the National Coordinator for Health Information Technology. All of the course materials are available under a Creative Commons Attribution Noncommercial ShareAlike (CC BY NC SA) License. The course description, learning objectives, author information, and other details may be found at http://archive.org/details/HealthITWorkforce-Comp01Unit04. The full collection may be browsed at http://knowledge.amia.org/onc-ntdc or at http://www.merlot.org/merlot/viewPortfolio.htm?id=842513.
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The Health IT Workforce Curriculum was developed for U.S. community colleges to enhance workforce training programmes in health information technology. The curriculum consist of 20 courses of 3 credits each. Each course includes instructor manuals, learning objectives, syllabi, video lectures with accompanying transcripts and slides, exercises, and assessments. The materials were authored by Columbia University, Duke University, Johns Hopkins University, Oregon Health & Science University, and University of Alabama at Birmingham. The project was funded by the U.S. Office of the National Coordinator for Health Information Technology. All of the course materials are available under a Creative Commons Attribution Noncommercial ShareAlike (CC BY NC SA) License. The course description, learning objectives, author information, and other details may be found at http://archive.org/details/HealthITWorkforce-Comp01Unit04. The full collection may be browsed at http://knowledge.amia.org/onc-ntdc or at http://www.merlot.org/merlot/viewPortfolio.htm?id=842513.
Copyright:
Attribution Non-Commercial ShareAlike (BY-NC-SA)
Formati disponibili
Scarica in formato PPT, PDF, TXT o leggi online su Scribd
Financing Healthcare (Part 1) Lecture d This material (Comp1_Unit4d) was developed by Oregon Health and Science University, funded by the Department of Health and Human Services, Office of the National Coordinator for Health Information Technology under Award Number [IU24OC000015)]. Financing Healthcare (Part 1) Learning Objectives Understand the importance of the healthcare industry in the US economy and the role of financial management in healthcare. (Lecture b) Describe models of health care financing in the US and in selected other countries. (Lecture c) Describe the history and role of the health insurance industry in financing healthcare in the United States, and Federal laws that have influenced the development of the industry. (Lecture a) Understand the differences among various types of private health insurance and describe the organization and structure of network-based managed care health insurance programs. (Lecture d) Understand the various roles played by government as policy maker, payer, provider, and regulator of healthcare. (Lecture d) Describe the organization and function of Medicare and Medicaid. (Lecture e) Health IT Workforce Curriculum Version 3.0/Spring 2012 2 Introduction to Healthcare and Public Health in the US Financing Healthcare (Part 1) Lecture d Payers in the US Healthcare System US Multipayer System Role of insurance How payers reimburse providers for healthcare services The Private Healthcare Payer System How health insurance works Sources of health insurance Types of health insurance Managed care Regulation of private health insurance Health IT Workforce Curriculum Version 3.0/Spring 2012 3 Introduction to Healthcare and Public Health in the US Financing Healthcare (Part 1) Lecture d Health Insurance Spreads the financial risk over a large pool of people Balances risk with cost 5% of the risk pool accounts for approximately 50% of the pool spending People over age 65 consume more health care than other age groups do Insurance cost is influenced by prescription costs, technology, an aging population, many with chronic conditions, government subsidies and plan administrative costs. Health IT Workforce Curriculum Version 3.0/Spring 2012 4 Introduction to Healthcare and Public Health in the US Financing Healthcare (Part 1) Lecture d How Insurers Pay Providers The provider submits a claim Claim must include at least one diagnosis code, and one procedure code for each service rendered Diagnosis code = ICD-9-CM Procedure code = CPT code or DRG code
A medical claims examiner or adjuster processes the claim Determines usual and customary charge Deducts any portion the patient is responsible for Deducts any contractual provider discount Reimburses the remainder Health IT Workforce Curriculum Version 3.0/Spring 2012 5 Introduction to Healthcare and Public Health in the US Financing Healthcare (Part 1) Lecture d How Insurers Pay Providers (continued) The patient and provider receive an explanation of benefits (EOB), also called remittance advice Regardless of whether claim is accepted or denied Regardless of whether the patient receives a check A claim can be denied for many reasons: Coding errors or insufficient information Procedure considered experimental or otherwise not covered by the policy Rejected claims can be appealed
Health IT Workforce Curriculum Version 3.0/Spring 2012 6 Introduction to Healthcare and Public Health in the US Financing Healthcare (Part 1) Lecture d The Multipayer US Healthcare System Contributors Private sources Employers and employees Contributions to private health insurance Out of pocket Other Public or government sources Federal & State and local Payroll and general tax revenues Special tax, e.g. sales tax 7 Health IT Workforce Curriculum Version 3.0/Spring 2012 7 Introduction to Healthcare and Public Health in the US Financing Healthcare (Part 1) Lecture d Public vs. Private Insurance Private insurance Primarily state-licensed companies Self-insured employer plan ERISA regulates Third-party administrator Public insurance is government or administered Medicare Medicaid Childrens Health Insurance Program (CHIP)
8 Health IT Workforce Curriculum Version 3.0/Spring 2012 8 Introduction to Healthcare and Public Health in the US Financing Healthcare (Part 1) Lecture d Types of Private Health Insurance Indemnity plans - traditional plans Fee for service Simply provide reimbursement to providers Less prevalent today Managed care plans prevail today Offer financial incentives to providers and patients Integrate the financing and delivery of care within a single system Health IT Workforce Curriculum Version 3.0/Spring 2012 9 Introduction to Healthcare and Public Health in the US Financing Healthcare (Part 1) Lecture d Blue Cross/Blue Shield Independent, state-licensed organizations Historically set up as not-for-profits under special state laws Blue Cross reimburses hospitals Blue Shield reimburses physicians Today, some Blue Cross/Blue Shield organizations operate as commercial insurers Health IT Workforce Curriculum Version 3.0/Spring 2012 10 Introduction to Healthcare and Public Health in the US Financing Healthcare (Part 1) Lecture d Managed Care Managed care: term for techniques designed to control costs and improve quality Managed care organization (MCO) a business model which integrates financing and delivery of health care using managed care techniques Features Comprehensive care Controlled access to care Manage outcomes and improve quality care Reduce costs Rationing and quality of care concerns Health IT Workforce Curriculum Version 3.0/Spring 2012 11 Introduction to Healthcare and Public Health in the US Financing Healthcare (Part 1) Lecture d Managed Care Organizations HMO = Prototype using capitation New models Mix and match reimbursement methodologies Greater patient choice Increased costs MCO Models Health Maintenance Organization (HMO) Preferred Provider Organization (PPO) Exclusive Provider Organization (EPO) Point of Service Plan (POS)
Health IT Workforce Curriculum Version 3.0/Spring 2012 12 Introduction to Healthcare and Public Health in the US Financing Healthcare (Part 1) Lecture d The Managed in Managed Care Managed care Delivers high-quality health care Controls costs Patient and provider incentives Utilization review Determine medical necessity of care Role as gatekeeper Different types of managed care plans Plan differences based upon cost and provider choice Health IT Workforce Curriculum Version 3.0/Spring 2012 13 Introduction to Healthcare and Public Health in the US Financing Healthcare (Part 1) Lecture d Cost vs. Provider Choice The various managed care plans are defined by choices in what providers the patient can use Fewer choices translate to lower health care premiums and lower out-of-pocket costs Types of managed care plans have varying degrees of choices and costs Health maintenance organization (HMO) Preferred provider organization (PPO) Point-of-service plan (POS) Health IT Workforce Curriculum Version 3.0/Spring 2012 14 Introduction to Healthcare and Public Health in the US Financing Healthcare (Part 1) Lecture d HMO Models Staff model: Doctors are salaried employees Group model: Doctors are employed by a group practice; the plan contracts with the practice for their services; most patients that a doctor sees are patients in that plan Open-group model: As above, but doctors are freer to accept patients from outside the plan Independent physician association (IPA): Doctors are organized into a legal entity; have autonomy but also contract with the plan Network model: The plan contracts with multiple independent physicians, group practices, and/or IPAs Mixed model: Mixes and matches any of the above Health IT Workforce Curriculum Version 3.0/Spring 2012 15 Introduction to Healthcare and Public Health in the US Financing Healthcare (Part 1) Lecture d Preferred Provider Organization (PPO) PPO - patients free to choose any provider In-network providers Lower deductibles, copayments, and coinsurance Out-of-network providers Higher deductibles and coinsurance for the patient EPO patients must use network providers No reimbursement for out of network provider services No gatekeeper for either a PPO or EPO Health IT Workforce Curriculum Version 3.0/Spring 2012 16 Introduction to Healthcare and Public Health in the US Financing Healthcare (Part 1) Lecture d Point of Service Plan Point of Service Plan Gatekeeper All services through the gatekeeper the point of service - controls access to all medical services Referrals generally to in-network providers only May refer out-of-network No reimbursement for services to out-of- network providers unless previously authorized by gatekeeper Health IT Workforce Curriculum Version 3.0/Spring 2012 17 Introduction to Healthcare and Public Health in the US Financing Healthcare (Part 1) Lecture d Indemnity vs. Managed Care Programs INDEMNITY MANAGED CARE Feature Fee for service HMO PPO POS EPO Provider network None Strict or exclusive Broad network Hybrid of HMO/PPO Hybrid of HMO/PPO Physician choice Unlimited PCP required PCP not required PCP required PCP not required
Referrals Not needed Must come from PCP Not needed Required if out of network None out-of- network Precertification Not needed Required Not usually required Not usually required Required Preventive care Usually not covered Covered Some covered Covered Varies Relative cost to patient High Low Mediumhigh Low-medium Medium 4.9 Table: (2011, CC BY-NC-SA 3.0). Health IT Workforce Curriculum Version 3.0/Spring 2012 18 Introduction to Healthcare and Public Health in the US Financing Healthcare (Part 1) Lecture d Regulation of Private Health Insurance States control the legal structure of private insurers and monitor their finances Purpose: To ensure the company can meet its obligations to the people it insures Private insurance companies are also regulated by federal laws Federal law may take precedence over state law Health IT Workforce Curriculum Version 3.0/Spring 2012 19 Introduction to Healthcare and Public Health in the US Financing Healthcare (Part 1) Lecture d Federal Regulation of Private Health Insurance Employee Retirement Income Security Act (ERISA) 1974 Permits and regulates self-insured health plans Does not require employer plan Requires plans to meet minimum standards Requires a grievance and appeals process Gives participants the right to sue for benefits Requires plan administrators to meet certain standards of conduct Health IT Workforce Curriculum Version 3.0/Spring 2012 20 Introduction to Healthcare and Public Health in the US Financing Healthcare (Part 1) Lecture d Regulation of Private Health Insurance (continued) Consolidated Omnibus Budget Reconciliation Act (COBRA) 1985 An amendment to ERISA, implemented in 1986 Allows employees to choose continuation of group health benefits in certain cases Voluntary or involuntary job loss Reduction in hours worked, Transition between jobs, Death of a spouse, divorce, and certain other life events Individuals may have to pay premium up to 102% of cost Generally required for group health plans of companies with 20+ employees Health IT Workforce Curriculum Version 3.0/Spring 2012 21 Introduction to Healthcare and Public Health in the US Financing Healthcare (Part 1) Lecture d Regulation of Private Health Insurance (continued) Health Insurance Portability and Accountability Act (HIPAA) 1996 Amendment to ERISA Defines protected health information and helps ensure its privacy Protects participants in group health plans Prohibits discrimination based on health status Provides additional opportunities to enroll in group health plan, after loss of coverage or certain life events For some people, guarantees access to individual insurance - American Recovery and Reinvestment Act (ARRA) of 2009 strengthened law and provided penalties
Health IT Workforce Curriculum Version 3.0/Spring 2012 22 Introduction to Healthcare and Public Health in the US Financing Healthcare (Part 1) Lecture d Regulation of Private Health Insurance (continued) ERISA mandated coverage Newborns' and Mothers' Health Protection Act 1996 Plans that offer maternity coverage must pay for at least a 48-hour hospital stay following childbirth Mental Health Parity Act 1996 Requires equality for coverage of mental illness Women's Health and Cancer Rights Act 1997 Provides for post-mastectomy benefits including reconstructive surgery and treatment of complications
Health IT Workforce Curriculum Version 3.0/Spring 2012 23 Introduction to Healthcare and Public Health in the US Financing Healthcare (Part 1) Lecture d Regulation of Private Health Insurance (continued) The Patient Protection and Affordable Care Act (PPACA) 2010 (Healthcare Reform Law) No limit or denial of coverage for children under 19 with preexisting conditions Adults no longer denied insurance due to preexisting condition Ends lifetime limits and most annual limits on care Allows children under 26 to stay on parents plan Some plans will provide free access to preventive services Provides 50% discount on brand-name drugs for seniors in the Medicare donut hole More benefits will be phased in through 2014
Health IT Workforce Curriculum Version 3.0/Spring 2012 24 Introduction to Healthcare and Public Health in the US Financing Healthcare (Part 1) Lecture d Financing Healthcare (Part 1) Summary Lecture d Insurance works by spreading financial risk Insurers pay providers based upon Diagnosis and procedure codes, contracted rates States license and regulate private insurance Types of plans include indemnity, Blue Cross and Blue Shield and managed care plans Managed care uses techniques that result in lower healthcare costs and improved quality Some Federal laws regulate private health insurance ERISA, COBRA, HIPAA, and the Affordable Health Care Act
Health IT Workforce Curriculum Version 3.0/Spring 2012 25 Introduction to Healthcare and Public Health in the US Financing Healthcare (Part 1) Lecture d Financing Healthcare (Part 1) References Lecture d References American Association of Preferred Provider Organizations. PPO resources. http://www.aappo.org/index.cfm?pageid=10. Accessed April 10, 2011. American Association of Preferred Provider Organizations. PPO Toolkit. http://www.aappo.org/AAPPO_Toolkit_FINAL.htm. Accessed April 2, 2011. Bihari M. Understanding the Medicare Part D donut hole: learn about the Medicare Part D coverage gap. http://healthinsurance.about.com/od/medicare/a/understanding_part_d.htm. Accessed April 7, 2011. Centers for Medicare and Medicaid Services. Childrens Health Insurance Program (CHIP). http://www.cms.gov/home/chip.asp. Accessed April 7, 2011. Centers for Medicare and Medicaid Services. http://www.cms.gov. Accessed April 7, 2011. Congressional Budget Office. Statement of Douglas W. Elmendorf, Director. CBOs analysis of the major health care legislation enacted in March 2010 before the Subcommittee on Health, Committee on Energy and Commerce, U.S. House of Representatives. March 30, 2011. www.cbo.gov/ftpdocs/121xx/doc12119/03-30- HealthCareLegislation.pdf. Accessed April 3, 2011 Cornell University Law School. Workers Compensation: an overview. http://topics.law.cornell.edu/wex/Workers_compensation. Accessed April 7, 2011. Kaiser Family Foundation. Health care costs: a primer. August 2007. www.kff.org/insurance/upload/7670.pdf. Accessed April 2, 2011. Kaiser Family Foundation. How private health care coverage works: a primer2008 Update. April 2008. www.kff.org/insurance/upload/7766.pdf. Accessed April 2, 2011.
Health IT Workforce Curriculum Version 3.0/Spring 2012 26 Introduction to Healthcare and Public Health in the US Financing Healthcare (Part 1) Lecture d Financing Healthcare (Part 1) References Lecture d References Levey NM. Questions and answers about new rules on appealing rejections of health insurance claims. Los Angeles Times. July 23, 2010. http://articles.latimes.com/2010/jul/22/nation/la-na-health-rules-qa-20100723. Accessed April 12, 2011. Marcinko DE. Understanding the Medicare Prospective Payment System. September 17, 2009. http://medicalexecutivepost.com/2009/09/17/understanding-the-medicare-prospective-payment-system. Accessed April 7, 2011. MCOL. Managed care fact sheets. http://www.mcareol.com/factshts/factnati.htm. 2011. Accessed April 9, 2011 Medicare.gov. Medicare Advantage (Part C). http://www.medicare.gov/navigation/medicare-basics/medicare- benefits/part-c.aspx. Accessed April 7, 2011. National Association of Workers Compensation Judiciary. http://www.nawcj.org. Accessed April 7, 2011. National Bureau of Economic Research. Prospective Payment System (PPS) data. http://www.nber.org/data/pps.html. Accessed April 7, 2011. Obringer LA, Jeffries M. How health insurance works. http://health.howstuffworks.com/medicine/healthcare/insurance/health-insurance.htm. Accessed April 2, 2011. Partners Human Research Committee. Overview of the HIPAA final privacy regulations. http://healthcare.partners.org/phsirb/hipaaov.htm. Accessed April 10, 2011. Purcell P, Staman J. Summary of the Employee Retirement Income Security Act (ERISA). Congressional Research Service report RL34443. May 19, 2009. http://aging.senate.gov/crs/pension7.pdf. Accessed April 3, 2011.
Health IT Workforce Curriculum Version 3.0/Spring 2012 27 Introduction to Healthcare and Public Health in the US Financing Healthcare (Part 1) Lecture d Financing Healthcare (Part 1) References Lecture d References Tufts Managed Care Institute. Managed care models and products. 1998. www.thci.org/downloads/ModelsProducts.pdf. Accessed April 10, 2011. U.S. Department of Health and Human Services and U.S. Department of Justice. Stop Medicare fraud: learn more about fighting fraud. http://www.stopmedicarefraud.gov. Accessed April 7, 2011. U.S. Department of Labor. Health plans and benefits. http://www.dol.gov/dol/topic/health-plans. Accessed April 11, 2011. U.S. Department of Labor. Workers Compensation. http://www.dol.gov/dol/topic/workcomp/index.htm. Accessed April 7, 2011. WorkersCompensation.com. http://www.workerscompensation.com. Accessed April 7, 2011.
Chart, Tables, Figures 4.9 Table: Indemnity vs. Managed Care Programs (2011, CC BY-NC-SA 3.0). 28 Health IT Workforce Curriculum Version 3.0/Spring 2012 Health IT Workforce Curriculum Version 3.0/Spring 2012 28 Introduction to Healthcare and Public Health in the US Financing Healthcare (Part 1) Lecture d