QUIZ 1 – HSA 312

EMPLOYER-BASED GROUP HEALTH INSURANCE:

DUE 11:59 PM, TUESDAY MARCH 30, 2021 – YOU MAY SUBMIT EARLIER IF YOU WISH.

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

MANAGED HEALTH CARE

SPRING 2021 L. EITEL

NOTE: THESE QUESTIONS ADDRESS KEY POINTS ABOUT U.S. HEALTH INSURANCE FROM 1929-2000. THIS COVERS MATERIAL FROM OUR SECOND CLASS THROUGH THE WEEK OF MARCH 15.

· 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:

A. BRIEFLY DESCRIBE THE TWO KEY APPROACHES TO AN RISK IN THE HISTORY OF GROUP HEALTH INSURANCE. READING A.

B. WHICH APPROACH IS ASSOCIATED WITH INDEMNITY/INSURANCE PLANS, AND WHICH APPROACH IS ASSOCIATED WITH MANAGED HEALTH INSURANCE (HMOs, POS Plans, PPOs (Preferred Provider Organizations)?

READING A.

THIS SHOULD BE A VERY SHORT ANSWER.

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

INDEMNITY AND SERVICE HEALTH INSURANCE PLANS:

A. USING ATTACHED READING 1, READING A.,PAGES 1 AND 2 ., AND READING

· 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? READING 1. AND READING A., PAGES 1 AND 2.

· PART 2: Deductibles and Coinsurance : READING B., PAGES 2-3 , OR READING 1., PAGES 2-3.

· Define the difference between a Deductible and Co Insurance?

· Are these two different forms of Out-of-Pocket Spending? YES or NO?

· 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? READING 1.

B. USING READING 1.,PAGES 3 AND 4 ATTACHED, ANSWER THE FOLLOWING:

· Between the 1930’s and the late 1960’s, how did the predominant Indemnity and Service Health Insurance plans CHANGE in terms of Out-of-Pocket Expenditures, and the Coverage of Physician and Hospital Services?

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

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

A. What was the major reason that employers, Blue Cross/Blue Shield plans, and commercial insurance companies moved private, employer – sponsored group health insurance from an Indemnity/Service Plan Model to a Managed Care Model between 1988 and 1996?

B. Briefly 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.

QUESTION 4: MANAGED CARE – THE KAISER PERMANENTE MODEL

[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.

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

· PART A: In the Kaiser Permanente Model of Managed Care:

· what is the relationship between the insurance plan and the provider network (especially physician groups and hospitals)?

· Is the relationship cooperative and positive, or adversarial, negative, and suspicious? – READING 2.

PART B: What is the Coordination function as performed by a Primary Care Physician or Primary Care Team, and why is it KEY to successful management of Patient Care?– READINGS 2.A., 2.B., AND 2.C. (SLIDES 5, 9-12).

QUESTION 5: 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 by the two predominant Managed Care Health Plans of the 1990s (HMOs, POS Plans) to influence and/or control provider and patient choices about the type, length and location 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