AAEC 2104 Lecture Notes - Lecture 20: Preferred Provider Organization, Health Maintenance Organization, Managed Care

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lavenderhound962

27 Apr 2018

School

Virginia Tech

Department

Agricultural and Applied Economics

Course

AAEC 2104

Professor

Alex White

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Finance Notes – Insurance

Health Insurance

- Basic Health Insurance

o Hospital Insurance

▪ Covers cost associated with a hospital stay

o Surgical Insurance

▪ Covers cost related to surgery

o Physician Expense Insurance

▪ Covers physician’s fees outside of surgery

- Dental and Eye Insurance

o Usually not provided by employer

▪ You pay the premiums

Private Health Care Plans

- Managed health care

o HMO’s pay for and provide health care services

▪ HMO = Health Maintenance Organization

• A point-of-service plan allows treatment from affiliated

and nonaffiliated doctors

• A preferred provider organization (PPO) is a cross

between traditional and HMO

- Group Insurance

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Document Summary

Basic health insurance: hospital insurance, covers cost associated with a hospital stay, surgical insurance, covers cost related to surgery, physician expense insurance, covers physician"s fees outside of surgery. Dental and eye insurance: usually not provided by employer, you pay the premiums. Group insurance: covers a group of individuals, usually much cheaper than individual plans. Savings plans established by the employer: pre-tax earnings. Employees withdraw funds to cover: un-reimbursed medical or dental expenses. Flexible spending account (fsa: contact lenses, prescriptions, etc, scheduled surgery lasik, etc, may be a (cid:498)use it or lose it(cid:499) plan ask, nott a (cid:498)use it or lose it plan(cid:499) Health savings account (has: for use with high-deductible health plans. Under the consolidated omnibus budget reconciliation act (cobra): if company has at least 20 employees, continue your coverage for 1 - 3 years after you leave the company, you pay full costs of the insurance. Provides medical benefits to: disabled, those over 65 who qualify for social security.

Related Questions

True of False

Bill is an aging snowboard instructor at a local ski resort. All winter, he takes over the counter pain medication to deal with his aching joints. Each summer, he moves home with his parents and takes a part time job making minimum wage. This summer, he got qualified for and enrolled into state government subsidized health insurance. Now he plans to undergo arthroscopic surgery by the end of the summer to repair his knee. Though this is an economically rational decision for Bill, it represents a welfare loss to society as a whole.

Catastrophic medical expenses are large, infrequent and unpredictable. Risk aversion explains why people buy insurance which covers such catastrophic events.

The primary funding source for the expenses of current Medicare beneficiaries is the fund current beneficiaries contributed to throughout their lifetime.

Many useful medical technologies become wasteful when they are expanded to include low-risk individuals.

A problem with Cost-Benefit Analysis is that

a) scientists observe peopleâs behavior to calculate how much individuals are willing to pay for a particular treatment.

b) opportunity cost is measured as the value of the next best alternative foregone.

c) the perspective of the one benefitting from the medical service must be included.

d) sometimes subtle distinctions in the alternatives considered as opportunity costs may overstate the benefits of a treatment.

e) the use of expected values employs the statistical law of large numbers and this is not acceptable for individual decision making analysis.

Which of the following is an example of adverse selection in the private health insurance market?

a) Consumers regularly engaging in bungee jumping but being able to hide it from their insurer, who developed premiums based on the average utilization rates of that large group in the past.

b) Consumers anticipating regular (twice a year) visits to the dentist for preventive care but being able to hide it from their insurer, who developed premiums based on the average utilization rates of that large group in the past.

c) Young and healthy consumers having access to multiple plans offered by the employer (from low-priced HMO and high-deductible plans to higher-priced PPO) and ultimately choosing the most comprehensive PPO plan.

d) Elderly people enrolling in Medicare.

e) Poor family enrolling their chronically ill children in Medicaid.

PROVIDE A RESPONSE OR STATEMENT TO THIS STUDENTS DISCUSSION:

1 - Please share your experience on selecting a managed care plan. Please discuss the advantages and disadvantages of your MCO plan.

Up until about ten years ago my company offered an HMO MCO plan option managed by Kaiser Permanente. This plan was less expensive in my paycheck deduction and offered $10 co-pays for every office visit and 100% hospitalization. In 1992 as a single young man in my twenties I found this option very attractive. I ended up getting married early that year, had a flu episode and a bout of food poisoning. My wife ended up with a hospitalization as well. What looked good on paper ended up being a very restricted healthcare experience. My office visits were restricted to only one clinic where the health care professional point of contact were physicians assistants under the supervision of an MD which we never saw. All of the prescriptions were for generic medicines and when my wife was hospitalized she was not allowed branded medicines either. We also thought she was discharged too early. The advantages of this type of plan are costs and simplicity. If we had not been sick that year we probably would have signed back up for it. The disadvantages were that our level of care was reduced to a less skilled health care professional and the attending physician who cared for my wife in the hospital discharged my wife early due to a time limit the HMO had placed on the length of stay for her illness code. That was the first and last year I chose an MCO plan for my health coverage.

2 - Many argue that there is no consistent, direct correlation between the cost of care and its quality in a managed care program. Do you agree or disagree?

In my personal experience managed care plans attempt to lower the primary care contact to non MD health care professionals such as Nurse Practioners and Physicians Assistants. While these clinicians are well trained and certainly have their appropriate place in medicine, they do not have the extensive medical training that MDs and DOs spend a minimum of 8 years mastering. These clinicians cost less than MDs and are very attractive way to reduce staffing costs. As a patient however I prefer the highest skilled level clinician caring for me and my family and am willing to pay more for this higher level of care. In my opinion Kaiser Permanente may have saved money but I was not happy with the level of care and medicines provided. They may have saved money that year but they lost me as a customer. Epstein et al, (2014) compared Accountable Care Organization (ACO) patients with non ACO patients and while they found that there were many differences in spending, age, and severity of illness, there was no difference in quality metrics despite non ACO members costing more overall. It would seem that in this example costs can be lowered without affecting quality outcomes. However ACO participants had access to significantly more participating clinicians and hospitals. What is missing from this study is a patient survey comparing the satisfaction of ACO and non-ACO patients.

3 - Do you think patients' choice of provider and access to care will be limited under ACOs?

In my personal experience and through observations of managed care offices and hospitals as a pharmaceutical representative, ACOs not only restrict the choice of provider and access to hospitals they utilize lesser trained medical professionals in Primary Care, Specialty and Hospitals in addition to restricting access to branded medications. This observation is in agreement with Epstein et al, (2014) in which ACO members cost less but had less access and choice of participating access points and clinicians.

4 - In what ways can an ACO succeed in both delivering high-quality care and spending health care dollars more wisely?

ACOs can be very useful in curbing costs. For those with limited health care budgets or those patients who receive public assistance an ACO model whether public or private. However Lewis et al, (2014) found that even though there was an almost even split between ACOs contracting for private and public contracts in the U.S.A., public contracts were less profitable than private ones due to public patients costing more to manage per capita than private ones. Quality was not examined. It would seem that an ACO would be ideal when faced with limited resources but ACOs may be reluctant to engage in contracts that are less profitable.


(Please Summerize the work down below, thank you)

Political	Economic
Growing political influences on healthcare advances	Cost of living increases
Global government influence on healthcare cost	Cost of insurance prices
Government control of Medicaid, Medicare funding	Rise of forecasted interest rates
Social/Cultural	Technical or Technology
Increase average age of population	Demand on new medical treatments
Patient expectations increase	Customize treatments
Demographics are in constant change	More advance service facilities
Environmental	Legal
Growing need for green business	Constant change of government drug Regulations
Environmental agenda and community awareness	Consumer laws
	Health and safety regulations



Porters 5 forces of business model

Competitive Rivalry
Growth opportunity for healthcare companies are expected to growing the next few years
Increase in new revolutionary drugs both in and outside of the US

Threat if New Entrants
Strict government regulations
Difficult to keep up due to constant change
Huge startup cost

Substitute Products
Threat of other substituting product and service at lower cost



Bargaining Power of Customers
Generic drugs offered at large discount to consumer
Larger less customized healthcare facility with lower housing costs
Several facilities offering similar services.

Bargaining power of supplier
Medical suppliers have a large pricing power
Bargaining power of physicians and nurses is huge because of large hospital benefits

Swot Analysis

Strengths

Highly trained and capable employees

Market experience

Strong leadership

High level of organizational efficiency

Excellent facilities

Strong commitment to bettering the community

Weaknesses

Increased cost of healthcare could lower our clientele

Limited staff resources

Limited cash flow to hire and train new employees

Lack of resources

Opportunities

Fast growing technology opens new doors for using state of the art equipment to better serve the patients.

Nursing and residential care is one of the fastest growing industries

Aging population

Threats

Uncertainty in political and economic climate causes hesitation for receiving new patients.

Funding constraints

Highly competitive market

Product or Service Analysis

Our services will be used by patients who cannot afford experimental treatments and patients who have been abandoned by the system because hospitals can no longer provide medical assistance. At our facility, we will be able to work with the families and provide them with different payments options, such as low monthly payment plans. Our main goal is to be able to treat the patient at a very affordable cost; however, if any patient does not possess the means to pay for treatment, he or she would not be turned away; our facility will tap into government and private funding to cover treatment cost.

The beauty of this service is that there isnât a charge of any kind to take part in our program because it is completely funded by government grants. Individuals that would take part would more than likely not have the means to pay a monthly deductible. Due to the nature of the business listed as a non-profit agency, there is no way to make a profit of any kind, as it would jeopardize the business in its entirety.

Some of the market factors that create a demand for our services include the need of medical care after having maximized all resources, the number of low income families, and the number of patients facing health issues needed extended medical care.

Opportunities that may derive from this business is the opportunity to expand and open multiple facilities, while extending a helping hand to many more in need. The risk, however, is the unstable funds deriving from grants. This can pose a huge treat to the business, as grants often times come and go and cannot be counted on as a constant income.

After studying the healthcare system and current policies in place, data shows many individuals facing severe health issues usually go untreated and uncared for due to the outrageous cost of medical care. It is devastating to see how often people, especially the elderly, are sent home and forgotten for the mere reason that hospitals and doctors are not willing to care for patients without financial means. In fact, in 2009 Harvard news reported 45,000 annual deaths due to lack of health coverage in the U.S. alone, which is significantly higher than the 18,000 reported by USA Today in 2002.

Financial Analysis

Clermont will be a nonprofit organization, dedicated to help the most needed. To open the facility fully operational we must take in consideration some fixed expenses like the land acquisition, permits, interest, brokers, administration fees, professionals (facility setup), staff, reports (environmental, occupational, fire, FDA), electricity, water, phone, water & sewer , connections, taxes, insurance, management, security, advertising, accountants, food, lawn mowers, bank fees, etc.

The facility will need have a total value of approximately three million dollars, but if we break the price of the land acquisition in to a thirty (30) year mortgage we can star up the business with an investment of approximately $ 233,944.61 USD to cover the first month of operation including all the startup permits and connections. After the first month the fixed expenses will be $184,444.00 USD with the exception of the months were taxes are due; taxes are around $ 43,000.00 USD paid quarterly will increase the tax month (depending on the facility fiscal year) for $ 10,750.00 USD approximately. We will fund all the costs with private and public funding, fundraiser, events, raffles, and most important with the help of the community.

As we mentioned before, Clermont is a nonprofit organization and we will do everything in our power to give the relief to the families in need. No one will be rejected because they do not have the money or the insurance cannot help. No money will be required from patient and every single dollar received will be spent in the patients, and in improving our facility and our service every day.

We believe our financial even breaking point will be a year after we begin operations, and be profitable soon after. There are many patients in need, and with the government and public grants each person will receive the treatment they need, and we will become the hope of many.

AAEC 2104 Lecture Notes - Lecture 20: Preferred Provider Organization, Health Maintenance Organization, Managed Care

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