Health Insurance Traditional Fee-For-Service Coverage Blue Cross-Blue Shield Plans Health...
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Transcript of Health Insurance Traditional Fee-For-Service Coverage Blue Cross-Blue Shield Plans Health...
![Page 1: Health Insurance Traditional Fee-For-Service Coverage Blue Cross-Blue Shield Plans Health Maintenance Organizations Preferred Provider Organizations Point.](https://reader036.fdocuments.in/reader036/viewer/2022082816/56649d8b5503460f94a72fc2/html5/thumbnails/1.jpg)
Health Insurance
Traditional Fee-For-Service Coverage
Blue Cross-Blue Shield Plans
Health Maintenance Organizations
Preferred Provider Organizations
Point of Service Plans
Current Health Care Concerns
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Traditional Fee-For-Service Coverage
BenefitsIndemnityServiceValued policy
Basic benefitsHospitalSurgicalMedical expenses
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Traditional Fee-For-Service Coverage - continued
Major medical insurance
Maximum limits
Internal limits
Benefit period
Coinsurance
Stop loss provisions
Limited contracts
Accident of specified illness
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Policy Provisions
Coordination of benefits
Continuation provisions
COBRA 1985
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Blue Cross-Blue Shield Plans
Not-for-profit organizations
Hospitals and physicians formed these insurance plans
Tax favored organizations
Reimburse hospitals at a discounted rate
Competition for traditional health insurers
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Health Maintenance Organizations (HMOs)
Prepaid health care coverage
Incentives of HMOs versus Fee-for-service plans
Advantages/disadvantages of HMOs
Choice of Doctor
Coverage for Checkups and Preventative Care
Out-of-Area Service
Filing Claims
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Preferred Provider Organizations (PPOs)
Coverage provider negotiates discounts with doctors and hospitals
Insured can choose PPO for better coverage
Introduces competition into health care
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Point of Service Plans (POS)
Hybrid arrangement combining a traditional fee-for-service plan with an HMO and/or a PPO
Whenever health care is required, participant can choose the managed care option or an alternative health care provider
Higher coverage for managed care
Reduced coverage for out-of-network treatment
Fastest growing health care plan for employees
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Health Care Coverage - 1
What health care coverage do you have?
A) Own coverage through employer
B) Coverage through a parent’s policy
C) Coverage through the U of I Student Plan
D) Coverage through parent’s and U of I Plan
E) No coverage/I don’t know
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Health Care Coverage - 2What type of health care coverage do you have?
A) Traditional fee-for-service or BCBS
B) HMO
C) PPO
D) POS
E) I don’t know
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Current Problem Areas
Health care costs
Managed care problems
Physician compensation and control
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Health Care Costs in US
• Total health care spending $1.9 trillion (2004)– Up 7.9%, 3 times rate of inflation
– $6,280 per person
– 16% of GDP• Higher than any other industrialized nation
• Other nations provide universal coverage
• 46 million uninsured (at least part of year)• Fastest rising cost for employers
– 11% annual increase 2001-2005
– $10,880 for family, $4,024 for individual (2005)
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Managed Care Problems• Getting treatment for serious ailment
– Primary care provider may be reluctant to refer patient to a specialist– Plan may refuse to cover expensive treatment– No coverage for out-of-network care
• Under fee-for-service, physicians were paid only if they provided a service– Problem – over treatment
• Under managed care, physicians have an incentive to keep treatment costs down– Problem – under treatment– Potential conflict of interest for physicians
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Physician Compensation and Control
• Starting compensation levels (2006)– General practitioners: $140,000 - 150,000– Specialists (Radiologists, Cardiologists, Orthopedic Surgeons):
$260,000 - 400,000– Financial incentive for physician to become a specialist
• Conflicts between physician and managed care plans– Delays in approving care– Denial of coverage
• Paperwork requirements
• Physician satisfaction levels declining