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BRIEFLY DESCRIBE THE TWO KEY APPROACHES TO AND DEFINITIONS OF RISK IN THE HISTORY AND PRACTICE OF GROUP HEALTH INSURANCE

QUIZ 1 – HSA 312

EMPLOYER-BASED GROUP HEALTH INSURANCE:

EVOLUTION OF HEALTH INSURANCE IN THE UNITED STATES FROM INDEMNITY/SERVICE PLANS TO MANAGED HEALTH INSURANCE

MANAGED HEALTH CARE 

FALL 2020         

¨    ¨    ¨    ¨    ¨    ¨

NOTE: THESE QUESTIONS ADDRESS KEY POINTS ABOUT U.S. HEALTH INSURANCE FROM 1929-2000. THIS COVERS MATERIAL FROM THE FIRST 3 CLASSES

  • FROM THE BIRTH OF EMPLOYER-BASED GROUP HEALTH INSURANCE;
  • TO THE FULL DEVELOPMENT OF THAT INSURANCE IN INDEMNITY AND SERVICE PLANS;
  • TO THE CRISIS OF HEALTH CARE EXPENDITURES IN THE 1970’S AND 1980’S;
  • TO THE TRANSITION TO MANAGED CARE;
  • AND THE MANAGED CARE BACKLASH OF THE LATE 1990s.

QUESTION 1: DIFFERENT APPROACHES TO/DEFINITIONS OF RISK IN GROUP HEALTH INSURANCE: READING A. AND READING B.

  1.  BRIEFLY DESCRIBE THE TWO KEY APPROACHES TO AND DEFINITIONS OF RISK IN THE HISTORY AND PRACTICE OF GROUP HEALTH INSURANCE.
  • WHICH APPROACH IS ASSOCIATED WITH INDEMNITY/INSURANCE PLANS, AND WHICH APPROACH IS ASSOCIATED WITH MANAGED HEALTH INSURANCE (HMOs, POS Plans, PPOs (Preferred Provider Organizations)?

QUESTION 2: DIFFERENT APPROACHES TO HEALTH INSURANCE FOR PERSONAL HEALTH CARE GOODS AND SERVICES:

INDEMNITY AND SERVICE HEALTH INSURANCE PLANS:

  1. USING ATTACHED READING 1 AND READING A.  ANSWER THE FOLLOWING:
  • PART 1: Did the Indemnity and Service plans which dominated the U.S. private group health insurance market from the 1930’s through the 1980’s focus on Financial Risk Management of health insurance benefits (making sure health plan expenditures did not exceed health plan revenues from premiums), or on broader Medical Risk Management of the health status of health plan enrollees?
  • PART 2: Briefly describe 2 ways in which these plans made sure that health plan enrollees would have to pay for some health services out-of-pocket: In other words, give 2 examples of enrollee Cost Sharing, and briefly define them.
  • PART 3: As a rule, prior to the 1970s, did Indemnity and Service health insurance plans actively attempt to manage physician and hospital decisions about the length of hospital stays, or the location and choice of medical treatments for patients? What was their overall attitude toward third-party interference in the decisions made by physicians and patients?
  • USING READING 1. ATTACHED, ANSWER THE FOLLOWING:
  • By the mid to late 1960’s, how did the predominant Indemnity and Service Health Insurance plans CHANGE in terms of Out of Pocket Expenditures, and the extent and number of hospital and physician Services Covered.

QUESTION 3: TRANSITION TO MANAGED HEALTH INSURANCE IN THE UNITED STATES:

USING READING 1.C. ATTACHED, ANSWER THE FOLLOWING:

  1. What was the major reason the Federal government, and eventually employers, Blue Cross/Blue Shield plans, and commercial insurance companies sought to move private group health insurance from an Indemnity/Service Plan Model to a Managed Care Model between 1975 and 1996?
  • Indicate the three (3) main ways in which the HMO Act of 1973 made it possible for Managed Health Insurance plans to spread beyond their regional strong holds on the East and West coasts.
  • Between 1988 and 1996, which forms of health insurance became prevalent:  Indemnity and Service Health Insurance Plans OR Managed Health Insurance Plans?

QUESTION 4: WHAT IS MANAGED CARE?

USING READINGS 2., 2.A., 2.B. AND 2.C. ATTACHED, ANSWER THE FOLLOWING:

  • PART A: What is one (1) of the main definitions of Managed Care? Describe in a bit of detail. – READING 2.

[NOTE: A PHILOSOPHY OF COMPREHENSIVE MEDICAL CARE MANAGEMENT WAS AT THE HEART OF THE ORIGINAL CONCEPT OF MANAGED CARE AS IT WAS DEVELOPED AND IMPLEMENTED BY KAISER PERMANENTE IN CALIFORNIA. AT THE CENTER OF THE PHILOSOPHY WAS THE NOTION OF CONTINUOUS, COMPREHENSIVE, COORDINATED CARE FOR PLAN MEMBERS AND THEIR FAMILIES.]

PART B: What is the Coordination function as performed by a Primary Care Physician or Primary Care Team, and how does it give Patients better care? – READINGS 2.A., 2.B., AND 2.C. (SLIDES 5, 9-12).

QUESTION 5: MANAGED HEALTH INSURANCE PLANS: COMPARING HEALTH MAINTENANCE ORGANIZATIONS (HMOs) AND PREFERRED PROVIDER ORGANIZATIONS (PPOs):

NOTE: In the 1990s, and even today, HMO health insurance plans are considered more restrictive than Preferred Provider Organizations.

USING ATTACHED READINGS 3 AND 4:

  • PART A: Describe briefly 2 of the main ways in which HMOs manage and direct the medical care delivered to enrolled plan members.
  • PART B: Describe briefly 2 ways in which PPOs differ from HMOs.

QUESTION 6: MANAGED CARE IN THE 1990s AND THE MANAGED CARE BACKLASH.

USING READING 5 AND READING 6., ANSWER THE FOLLOWING:

  • PART A: Briefly describe two (2) of the Managed Health management techniques used predominant Managed Care Health Plans of the 1990s (HMOs, POS Plans) to influence and/or control provider and patient choices about the type and source of medical treatment. READING 5
  • PART B: Briefly describe two (2) positive accomplishments of Managed Health Insurance Plans in the 1990s. READING 5
  • PART C: Briefly describe one (1) key reason for Provider opposition to Managed Health Insurance as it was implemented through HMOs and Point of Service Plans. READING 6
  • PART D: Briefly describe one (1) key reason for Patient/Health Plan Enrollee opposition to Managed Health Insurance as it was implemented through HMOs and Point of Service Plans. READING 6

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