The Way How Care Is Showed part ii

This post is actually a continuation of my previous post, "The Way How Care Is Shows" as health Insurance and Managed Care have are technically correlate to one another. The root of the topic tree for me to elaborate here is,

"THE CONCEPT OF MANAGED CARE AND VARIOUS ROLES OF THE LOCAL GOVERNMENT"

What is MANAGED CARE?

Referring to Bashir Mamdani, Meenal Mamdani in the book of "Managed Care in the USA: History and Structure", managed care combines financing and delivery of health care in a single entity with the aim of improving quality of care while controlling costs.

After listened to the lecture given by Mr. Gatot Subroto (PT.Askes KCU Yogyakarta) and through further reading about it, I understand managed care as a system that controls the financing and delivery of health services to members who are enrolled in a specific type of health care plan. Read further as I'm giving the examples and explanations of the plans provided for a better understanding about this thing:)

 What's the purpose? Any GOALS to set up to?

To ensure that:

• providers deliver high quality care in an environment that manages or controls costs.
• the care delivered is necessary and appropriate for the patient’s condition.
• care is provided by the most appropriate provider and settings.

In general: To eliminate inappropriate tasks and ensure that cost effective practice is adapted.

How does it works?

Briefly say, managed care works through modifying the actions of doctors (or other professionals initiating care) to reach its goals.

Do managed care have any level of its implementation or success?

It's measured in a way of growth of its maturity from 1st Generation to 5th Generation.

Generations	Main points
1st	i.    Retrospective utilization review Doctors do something --> they review it --> they correct it ii. 2nd opinion programme Comparing one provider to another Eg. Dr Taufiqah is having a patient with a heart problem. She discussed it with Dr Nazshua and he suggested that the patient needs an open heart surgery. Dr Taufiqah then asked Dr Djoko who had been a cardiologist for 20 years to get his opinion. Dr Djoko will do the examination and he’ll decide the management.
2nd	Increase use of capitation and gatekeeper (Primary Care Provider) by ensuring that the reference system is really works.
3rd	i.      Management of high cost cases         ii.      Providing or profiling Eg. Comparing one Rumah Sakit to another Rumah Sakit of the same class level.       iii.      Clinical practice Guidelines
4th	i.      Increasing interest in health outcomes         ii.      Health plan report cards (league)       iii.      Health system integration       iv.      Improved information system and system monitoring
5th	i.         Anticipatory case management       ii.         Targeted disease management     iii.         Outcomes- based reimbursement     iv.         Community- based needs assessment

*The examples I gave are based on my understanding by what the guest lecturer conveyed. Please correct me if I'm wrong. Thank you very much*

• ASKES in Indonesia are now reaching between the 3rd to 4th Generation.
• The 4th Generation features are now developing in US.

What are the major types of Managed Care plans?

Health Maintenance Organizations (HMO)	Preferred Provider Organizations (PPO)	Point of Service (POS)
HMO + Health care providers --> “Provider Network” A contracted provider provides services to health plan members at discounted rate in exchange for receiving health plan referrals.	PPO + Health care providers --> “Provider Network”	POS + Health care providers --> “Provider Network”
Members must only see providers within this network to have their health care paid by the HMO.	Members have no gatekeeper nor do they have to use an in- network provider for their care.	1.Often called an HMO/ PPO hybrid or an “open- ended” HMO 2.It’s called “point- of- service”: Members choose which option (HMO or PPO) they will use each time they seek health care.
Members select a Primary Care Physician (PCP) i.e. the gatekeeper.	Offers members “richer” benefits as financial incentives. Eg. If Miss Taufiqah sees an in- network family physician for a routine visit, she only has a small co- payment or deductible. If she sees a non- network family physician, she has to pay as much as 50% of the total bill.	Encourage, but don’t require members to choose a PCP.
Most restrictive because providing members the least choice in choosing a provider.	Less restrictive than HMOs in the choice of health care providers.	Offers more flexibility and freedom of choice.
Provide members with a greater range of health benefits for the lowest out- of- pocket expenses.	Require greater out- of- pocket payments from the members.	Members who choose not to use their PCPs for referrals (but still seek care for an in – network provider) still receive benefits but will pay higher copays and/ or deductible than members who use their PCPs.

All of all, this intended to reduce the cost of providing health benefits and improve the quality of care :)

Frankly speaking, before I had a discussion about this, I actually confused on how POS really works. Reading alone 2, 3 times made me dizzier@_@ Hence, a bunch of THANKS to my group members (Group 8 For The Win~) for giving a good explanations about it during the tutorial sessions and to our tutor, dr. Luthfan Lazuardi for the kind assistance.

Back to INDEX

References:

• "MANAGED CARE", Guest Lecture by Gatot Subroto (PT.Askes KCU Yogyakarta)
• "Physisician Income and Its Impact on Quality: GROUP 8 TUTORIAL SESSIONS (Week 2)
• Advantages & Disadvantages of HMO, PPO & POS Plans 

The Way How Care Is Showed

My today's post is about:

"THE USE OF HEALTH INSURANCE IN FINANCING MEDICAL HEALTH SERVICE"

  

What is Health Insurance?

• It is basically a promise by an insurance company or health plan to provide or pay for health care services in exchange for payment of premiums.
• form of collectivism by means of which people collectively pool their risk, in this case the risk of incurring medical expenses.

In Indonesia, PT Askes Indonesia is one of the social insurance company that carries out health insurance to its members who are mainly civil servants and non-civilian. Their children are also guaranteed up to the age of 21 years. The retiree and his wife or the husband is also guaranteed for life.

Beyond the categories above, there are other health insurances provided:

Jamkesmas Jaminan Kesihatan Masyarakat	Programme of the Government Under Department of Health for low-income people financed by the state budget (APBN)
Jamkesda Jaminan Kesehatan Daerah Jamkesos   Jaminan Kesehatan Sosial	Under the provincial and district governments. Eg: In South Sumatra province, it’s called Jamsoskes.

Trust me, if you ever had to pay for health services yourself, you might be shocked with how high the cost are. In fact, most people will not be able to afford to pay for major health services themselves. Lets just take myself as an example on the use of health insurance in financing medical and health service:)

I was admitted in JIH in the previous May for Dengue Hemorrhagic Fever. The total of my 5 days of hospitalization, doctor's fee (Jasa visit Dokter Spesialis i.e room visit specialist), the medications, supplements, all those diagnostic and laboratories procedures, and many other things in the list costs me Rp 14 million (and plus plus plus). I am the member of Takaful Indonesia Insurance and under specific terms and conditions, I only had to pay around Rp 400 000 which goes to the supplements and extra bedding for extra people to stay with me during my stay. It's a jackpot having to pay only that much for a good, first class service:)

Simply say, we won't get stuck paying for the entire bill. Why? Because we are insured against the high cost of medical care in the event that we need it.

Back to INDEX

References:

• "MANAGED CARE", Guest Lecture by Gatot Subroto (PT.Askes KCU Yogyakarta)
• "Physisician Income and Its Impact on Quality: GROUP 8 TUTORIAL SESSIONS (Week 2)
• Advantages & Disadvantages of HMO, PPO & POS Plans 

A PENNY for A GIFT OF SERVICE

"THE PAYMENT SYSTEM AND MECHANISM FOR PAYMENT IN RELATION TO THE PROFESSIONAL ROLES OF MEDICAL DOCTORS"

This topic had been such a hot topic during my group tutorial session. It's always something to put much interest on when it comes to MONEY, don't you think? :) I would like to dedicate a special thanks to the Indonesian friends in my group: Shendy Isyanto and Widyantri Wulandini for their many information shared with us about how doctor's payment in Indonesia is actually is.

Provider Payment Mechanism or simply put as the way of paying the doctors (and other health care-related bodies) are generally categorized into two types:

Let’s focus our discussion on Doctor’s payment which becomes one the most important aspect in DOCTOR’S LIFE SATISFACTION.

 

Notes: minus cost of providing practice and income tax

We move on to each of these income sources. I hope this table I made allowing an easier understanding for everyone :)

SALARY	FEE- FOR- SERVICE	CAPITATION
Monthly payment	Service- based payment	“Per- member- per- month” rate
Medical treatments are not influenced by economic incentive	Market forces mechanism	A fixed payment remitted at regular intervals to a medical provider by a managed care organization for an enrolled patient
Pros
Easier planning and budgeting	·         Increase patient satisfaction as doctors give more attention ·         Doctors are happy as income depends on the productivity	·         For Doctors: Doctor is paid by the insurance company for being listed as that patient's primary provider, even if no services are provided. It’s fixed, monthly. ·         For health insurance companies: Helps control the costs of health care, since providers will not likely recommend unnecessary procedures if they are responsible for the cost of these services.
Cons
Doctors may not deliver service to the fullest because he’ll get his salary regardless how poor his service is.	·         Hard to make a standard fee ·         Tendencies for supplier induced demand ·         Increase health inflation	Decrease patient satisfaction as doctors pay less attention

“FEE- FOR- SERVICE”

Impacts in Indonesia:

1. No standard income (unlimited incentives)

The wide variety of how the payment is made causing confusions of what is the exact appropriate payment for doctors. A doctor works in more than one hospital and more working hours certainly get higher payments compared to a doctor working otherwise. This kind of situations for instance, as what you can see in Indonesia; leads to the increasing gaps of the income between doctors .

 2. Supplier Induced Demand

Doctors intentionally increase the demand of hospital care based on economic incentive, not patient needs. For example, the essential management for patient having non specific low back pain is the prescription of NSAID (one of the analgesics example) and proper rest. But a doctor may inappropriately asked the patient for imaging test or physiotherapy, etc.

“CAPITATION”

I have given the definition and some explanations of capitation on the table above and perhaps my understanding correlated well with the concept:)

It's basically can be like, let say, I have 100 members from Insurance Company Gadjah Mada. The capitated rate is Rp 60 000 per member per month, meaning, I'll receive Rp 6 000 000 per month from Insurance Company Gadjah Mada to manage its 100 members regardless of the number of times that the 100 patients require my services or the amount of health care expenses I incur during this visit.

Many of the patients (insured members) may rarely see me, but I'm paid by the Insurance Company Gadjah Mada for being listed as the patients’ primary provider, even if no services are provided. It's like winning a lottery, eh? ^^

Back to INDEX

References:

• "Provider Payment Mechanisms", Lecture by dr. Laksono Trisnantoro and dr. Sigit Riyarto
• "Physisician Income and Its Impact on Quality: GROUP 8 TUTORIAL SESSIONS (Week 2)
• The American Heritage® Medical Dictionary
• McGraw-Hill Concise Dictionary of Modern Medicine
• AMERICAN COLLEGE OF PHYSICIANS: Understanding Capitation
• Case management: a practical guide to success in managed care 

An ice for a hot coffee

A much larger and more explosive Merapi eruption occured on 1am, Friday, November 5, 2010. I was in a truly deep sleep I didn't realize the thunder clatter- like sounds of the volcanic eruptions heard by my housemates. 

I woke up as usual for my Subuh prayer, had my breakfast, then I did my study. I was bothered by nothing but the gray ashes which had been filling the atmosphere since days ago. My housemates and I gathered in our pallor for a together- breakfast while watching the news which most broadcasting about the eruptions. Then I felt the heat of worrying and scared. 

Malaysian Embassy had us evacuated that morning, at 9.45am to be exact. It was an experience I shall reminisce till forever. The ashes, the eruptions, those emergency situations..

It’s very unfortunate that UGM were closed that all of us missed the opportunity to have a guest lecture from the Ministry of Health. I hope we'll still have the chance to have a talk with people from such department.

PRAY FOR INDONESIA