hsa 3111: health services financing 1 dr. lawrence west, health management and informatics...

HSA 3111: Health Services Financing

1Dr. Lawrence West, Health Management and Informatics Department, University of Central Floridahttp://systems.cohpa.ucf.edu/lwest

Topics

• Financing Complexity• Insurance• Public Financing for Healthcare• Payments and Reimbursements• Issues and Trends

“Financing is the lifeblood of any health care delivery system. At a basic level, it determines who will pay for health care services for whom.”

Text, p. 237



Financing Complexity

• Healthcare Financing in the U.S. is distinguished by stunning complexity compared to other developed countries

• A dizzying array of payers– Private insurance companies– Government agencies– Out of pocket



Financing Complexity (cont.)

• A single provider billing for a single type of procedure may face– Different rates allowed by each of several payers– Still a different rate for uninsured patients– A different mix between patient and payer

payment responsibility for the procedure– The possibility of multiple payers for the same

patient and procedure– Different patient payments depending on

deductibles, prior payments, and/or their insurance policy




• Some payers contract with other agencies to administer their programs– Piggyback on the administrator’s network of

providers and administrative systems– Piggyback on the administrator’s office systems

• Processing • Money management• Administration • Payment




• Three functions of HC Finance– Financing—providing the money– Insuring

• Assuming the risk• Administering the programs

– Paying—Paying providers• Service providers are the fourth element of the

HC system, delivery• HMOs may integrate all four functions



Financing Healthcare

• Most Americans receive healthcare paid by insurance– Private insurance– Medicare– Medicaid/SCHIP

• Out of Pocket includes– Uninsured payments– Copays and

deductibles for insured individuals



Financing Healthcare (cont.)

• Payment for the insurance coverage comes from various sources– Employer health insurance: Employer and

employee contributions– Private health insurance: The Insured pays all

costs– Medicare: Medicare taxes + General taxes– Medicaid: General revenue taxes



Insurance

• Insurance is a mechanism for protecting against risk

• Insured persons face probabilities of bad things happening to them– Accident – Illness– Death – Fire

• An adverse event has a financial cost• The expected value of the event is the probability

of the event occurring times the cost of the event if it occurs

E EEP CEV



Insurance (cont.)

• The total risk faced by an insured, i, is the sum of all risks for that person or company

• The insured pays an amount covering risk plus overhead– Profit– Administrative costs– Marketing costs

i Ei Ei EiE E

R EV P C

i iPmt R O



Insurance (cont.)

• Insurers calculated the expected risks and costs they will face for large groups of people and price policies accordingly– Revenues are the sum of all payments– Some insurers are able to invest retained

premiums (not a big factor in health insurance)– If actual adverse event occurrences are higher

than expected and/or actual costs of adverse events are higher than expected then profits are reduced

ii

R Pmt



Insurance (cont.)

• Insurers (cont.)– If actual occurrences and/or costs are lower than

expected then profits are higher– Insurer profits = Premiums + investment income

– loss payments – underwriting expenses

– While the probability of an adverse event for any one person is tough to predict the probability over thousands of people is much more reliable

– Insurers make money by pooling risk to stabilize their expected payouts



Insurance (cont.)

• A “moral hazard” exists when – One party has private information about a

transaction– The private information affects the value of the

other party’s participation in the transaction



Insurance (cont.)

• Moral Hazard (cont.)– If a person knows of a health condition that is

more likely to lead to an expense (↑PEi) than for the ‘average’ person…

– …And if the insurer is unaware of this risk • The person receives a discount on insurance • The insurer will pay more than expected in

claims– We will see this concept in the pricing of different

insurance products

i Ei Ei EiE E

R EV P C



Insurance (cont.)

• Individual Private Insurance– Individuals purchase insurance on their own

directly from an insurance company (or HMO)– This insurance is usually much more costly than

group insurance (next slide) because there is a moral hazard component to the market

• How does this hazard come about in this circumstance?

– Many types of people use individual insurance• Self employed • Early retired• Unemployed • Employees with no plan



Insurance (cont.)

• Group Insurance– Employer, Union, and Professional Organizations

often constitute “Groups” which contract with an insurer for insurance

– Typically, all members of the group must participate in the insurance program

– Mandatory participation reduces moral hazard• Healthy and unhealthy employees (and family

members) must participate• Healthy payments cover payments to unhealthy• The larger the group the more stable the costs



Insurance (cont.)

• Group Insurance Tax Implications– Employer contribution is a tax deductable expense– (Most) benefits received by employees are not

taxed as income• If employer gave contribution directly to the

employee– Employee pays tax on the income– Pays higher rates for individual insurance

• Employee contribution also “pre tax”– Employers becoming less generous as

unemployment rates go up



Insurance (cont.)

• Employer Self Insurance– Large enough employers can self insure– Bear the risk of payouts– Don’t have to pay insurance

company profit or marketing costs (↓Oi)

– Typically contract with a traditional insurer to administer the plan

– Self insurance plans are also exempt from providing some mandatory coverages

– 55% of covered employees were in self insured plans

i iPmt R O



Insurance (cont.)

• Managed Care Plans– HMOs and PPOs group more of the functions of

financing into a single organization• Insuring• Paying• Providing services

– Employees in HMOs– Contracted providers in PPOs

– Managed Care plans have more control over costs in the overall transaction



Insurance (cont.)

• Cost Sharing spreads payment risk to insured– Deductable—amount insured must pay before

benefits begin– Co-pay—amount insured must pay when services

are rendered• Provider Payment = Co-pay + Insurance Pmnt



Insurance (cont.)

• Personal Implications– The entire insurance function has extreme

personal implications for you– You should always be aware of

• What benefits, including covered services, co-pays, stop losses, etc., you have

• What your options are if you lose your current coverage

• How legislative or regulatory changes may affect you personally



Public Financing for Healthcare

• Numerous public (government) health financing programs exist– Military, retired military, veterans,

and military family coverage– Medicare and Medicaid (1965)– PACE (1997)– SCHIP (1997)



Medicare

• Four types of coverage– Part A: Hospitalization– Part B: Non-hospital medical insurance

• Voluntary• Mixed funding: Premiums + gov’t subsidy

– Part C: Managed Care Programs for Medicare participants

– Part D: Prescription coverage



Medicare (cont.)

• Medicare Financing– Medicare Part A (and later Part C & D) have been

funded by current workers for current eligibles– Excess contributions go into trust funds

• Supposed to cover future needs, including the aging baby boomers

• Projections call for depletion of the trust funds by 2018 (right when I need them)



Medicaid

• Health services for the indigent– A “means-tested” program

• Medicaid is administered by each state– Federal government contributes funds

• Level of coverage varies from state to state– States provide additional funding– States set eligibility requirements– States set benefits coverage



Other Programs

• PACE (Program of All-inclusive Care for the Elderly)– Combines Medicare and Medicaid coverage– No co-pays or deductibles

• SCHIP (State Children’s Health Insurance Program)– Covers uninsured children– Less restrictive eligibility (higher income threshold)

than Medicaid



Other Programs (cont.)

• Military Health Services System– Many components– Mix of insurance and employed and contract

providers– Available to active duty, dependents, and retired

and retired dependents• Veterans Health Administration

– Veterans with service-connected conditions (first priority)

– Veterans with income limitations– Dependents of veterans killed on duty



Other Programs (cont.)

• Indian Health Service– Clinics, public health, dental, and other services – Focus of services is near Native American

populations



Payments and Reimbursements

• Large payers and providers negotiate or set rates of reimbursement for services

• There are different approaches to setting rates– Fee for service: Specific rates for a specific

service• Providers have incentive to provide services• Neither provider nor insured patients pay the

costs



Payments and Reimbursements (cont.)

• Rate Setting (cont.)– Bundled Charges

• Bundles related specific services into a bundle for a more general definition of the service

• Sets rate for the bundled services• Specific patients use more or fewer specific

services for the more generalized treatment• How does this approach shift incentives?




• Rate Setting (cont.)– Resource-Based Value Scale

• Specific treatments are categorized by– Time ‒ Effort– Expertise

• A base cost factor is established– Varies geographically

• Payments based on base cost factor x value• Only the base cost need be adjusted over time• Used for Medicare payments




• Rate Setting (cont.)– Diagnosis-Related Groups

• Each group is a diagnosis with an expected– Bundle of services that will be needed– Total cost

• Rates are set for the diagnosis group• Adjustments made for

– Geographic area– “Outlier” patients




• Rate Setting (cont.)– Case-Mix Methods

• Patient condition-based analysis determines expected expenditures

• Patient condition places them into groups that are “uniform in their consumption of services”

• Payment made on historical consumption by the group, not on specific uses of services by the patient



Issues and Trends

• Pay For Performance– Healthcare financing is marked by a disconnect

between three parties• Decision makers• Payers• Beneficiaries (consumers)

– Theory predicts that healthcare will be over used (cost more)

– In theory P4P attempts to induce decision makers to make more cost-effective decisions



Issues and Trends (cont.)

• Insurance Continuity– An employee’s current insurance plan and the

potential cost or loss of coverage for a new plan skew decision making

• Job lock—staying with a job for the benefits even if it is not a good prospect

• Impeding small business start-ups– COBRA and HIPAA provide for continuation of

employer coverage at employee expense– Also prohibited preexisting condition exclusions– Provided some tax benefits



Issues and Trents (cont.)

• Erosion of Private Insurance– Large numbers of individuals are uninsured or

underinsured– Income levels where uninsured families exist are

rising– Financial conditions affect gross figures

• Employers not needing to be as competitive• Employers using more part-time employees

(not eligible for benefits)




• Risk Selection– Insurers are able to treat individuals differently

based on medical history– They can deny, reduce, or charge extra for

coverage– Insurers would prefer nothing but healthy people in

their risk pool– Everyone else faces high costs or no coverage




• Financing the Uninsured– Uninsured patients do receive healthcare– Use about half the healthcare of the insured – Are often unable to pay when they do receive

treatment• Governments and hospitals must step in to pay• Providers (usually hospitals) must cover

unreimbursed treatments by increasing costs to paying patients




• Fraud and Abuse– The sheer magnitude of the HC financing system

makes fraudulent activity attractive– GAO estimated that 10% of health spending is

fraudulent• Claims for nonexistent patients• Claims for procedures never rendered• “Upsizing” treatments

– Enforcement resources are inadequate

hsa 3111: health services financing 1 dr. lawrence west, health management and informatics...

Documents