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HCMG 1010, Exam 2
Physicians and Payment Reform
| Question | Answer |
|---|---|
| What are the patient cost controls? | Out of pocket at point of service, skin the game and cost sharing |
| What are provider cost controls? | payment design, provider accountability and paying for value |
| What is fee-for-service? | historical basis for payment, every service is associated with a particular payment, which insurer agrees to pay physician if service is performed, physician decides on treatment course, bills the fee for each service provided |
| What are two things that payment method influences? | volume of services provided (FFS -> paid more to do more), types of services provided (FFS -> high margin services over low margin services) |
| If payment methods are improved, they can influence the following | improve quality, outcomes, and value |
| How are prices set in FFS? | prices negotiated/set in fee schedules |
| Who bears the risk of any overuse or complications in FFS? | insurers |
| What is the incentives in FFS? | more volume means more revenue, more expensive services mean more revenue |
| What are some concerns about FFS? | encourage over-utilization, distort care provision if relative prices not set exactly right |
| What is the formula to develop relative prices? | resource-based relative value scale (RBRVS) |
| How to calculate RVU? | total work + practice cost + professional liability cost |
| How to calculate total work for RVU? | intensity * time |
| How to calculate practice cost for RVU? | personnel, rent |
| What is affiliation measure? | alignment in preferences between specialities proposing a pric and specialities on RUC evaluating proposal, based on share of revenue from services both specialties use |
| What is one criticism of RUC and RBRVS? | there is evidence of relative price distortions and regulatory capture |
| How would undoing relative price distortions help decrease bias? | reallocate revenue across specialties |
| What is one criticism of RUC and RBRVS related to valuation? | valuation is derived entirely from input costs, there is no validation with direct observation |
| How does RBRVS influence healthcare costs? | can influence procedure choice, health outcomes, total healthcare costs if incentives tilted towards performing more expensive procedures versus lower cost options |
| How did Medicare grow in the late 1990s? | annual budget target for doctor payment was tied to GDP growth, fees cut/increased based on target |
| What changed in 2002-2015 on how doctors got payed based on Medicar? | Congress prevented cuts from going into effect, no individual-level incentives to reduce costs or change utilization |
| What is MACRA in 2015 | Medicare Access and CHIP Reauthorization |
| Why does private prices follow Medicare? | private payment to a profit-maximizing physician is correlated with opportunity cost, goes against conventional wisdom of "cost shifting" - that reductions in Medicares payment rates are partially offset by private payment increase |
| What is pay-for-performance FFS+? | providers are rewarded or penalized by whether they meet pre-determined quality benchmarks |
| What is the goal for pay-for-performance FFS+? | pay for what we actually care about - quality of care and patient outcomes |
| What are the problems for pay-for-performance FFS+? | difficult to measure quality and health; low-powered cost reduction incentives; teaching to the test; cream-skinning; salience of quality metrics |
| What are shared savings programs for FSS+? | providers form organization to facilitate coordination and cooperation among healthcare providers and improve the quality of care |
| How does shared savings programs work? | are assigned benificiaries where they get most of their primary care, share percentage of savings they generate if expenditures of the assigned beneficiaries are below their benchmark and meet quality standards |
| Where do the savings come from for a shared savings program? | bundled payments (episodes of care as the base of payment) |
| What is the financial incentive of bundling payments for a shared savings program? | incentive to decrease costs per case, no incentive to decrease volume of cases |
| What are the potential effects of bundled payments? | improve coordination of care, reduce unnecessary uilization BUT it can skimp on care or cherry-pick patients |
| What is capitation payment per patient? | risk adjusted payment per patient per period |
| What is primary care for capitation? | just for primary care clinical services |
| What is secondary care for capitation? | secondary providers paid out of the provider's funds |
| What is global/full care for capitation? | covers all services for a patient - typically physician, hospital or postacute care |
| Where are salaries with bonuses seen for physicians? | military, IHS, academic settings, hospitalists employed by a hospital, primary care providers in a large group practice |
| Why are bonuses problematic though for physicians? | linked to productivity incentives - practice still being paid FSS, want to align incentives of docs |
| What was learned about voluntary participation from the Center for Medicare and Medicaid Innovation (CMMI) | providers wil participate in voluntary models on an ongoing basis only if they believe it is in their economic interest to do so |
| What was learned about the number of models created based on CMMI study? | proliferation of models create conflicting incentives, hard for providers to develop a cohesive strategy |
| What is crucial to determine if models work from CMMI? | benchmarking crucial for determining if costs go up or down, typically set based on average population spending; low cost providers choose to participate |
Created by:
goldengalleon