DIP Episode 658 - The Clutch Health Insurance Podcast (Part 3)

All right, welcome. My name is Devine. This is episode 658 of the Divine Intervention Podcast. Right, then into this podcast we're going to be finishing up the series on health insurance. Right. Again, if you missed part one and part two, you should go back and listen to those. I think you'll find those to be really helpful with your study. So let's just jump right into it. Right. So again, we've talked about a bunch of things. So let's maybe go into the discussion of just a few more kind of higher points that pop up on the exams. Right. So let's talk about also managed care plans. I think that's kind of a useful thing to know. All right. So first, so managed care plans. Right. So let's kind of talk about these. I think as I discussed in your understand what why classify them as managed care plans. Right. So the first one is going to be a HMO, a health maintenance organization. Right. So this is super restrictive. It can be pretty effective, but it is super restrictive. Right. Basically, if you're a member of this kind of plan, you know, you must choose a primary care physician. And then that primary care physician is like the referee. Right. They are like the gatekeepers. Right. If you want to see any kind of specialist, you need to get a referral from the PCP. Right. You need to get a referral from the PCP. Right. Generally, they don't cover out of network care. Right.

So if a person is not, if a physician is not within the HMO, you're not getting, you're not getting covered. Right. So out of network care, generally, not covered except for like an emergency. Right. But it's like you're like, man, this is so restrictive. What do I get in a change for this? Well, the thing you're going to get in return is the premiums are pretty low. Right. The premiums are pretty low. Right. And HM Os, they tend to use capitation to PPC Ps. Remember, we talked about capitation with the last podcast, where it's like, oh, you get paid a fixed amount per patient. Right. And we said that under under utilization can be the bugaboo with that method of reimbursement. Right. So again, if they give you a question on your exams about a patient that, you know, for example, needs to see a cardiologist, hasn't got a referral from her PCP. Right. And they're telling that, oh, the HMO is not willing to pay for it. Then they ask you like, what should this primary care physician do? Well, the primary care physician picked the answer that talks about, you know, helping the patient to navigate the referral process, documenting medical necessity. So that person can get the care that they need. Right. All right. So next, let's talk about a PPO, a perfect provider organization. Right. So what in the world going by a PPO, right, is basically similar to a HMO, but it's more flexible. Right. It's more flexible. Right. You can pretty much see any provider.

If you remember PPO, right, you can pretty much see any provider in network out of network. It doesn't matter. Right. Without the referral, you don't need the referral on like what we have for HMO. Right. But if you get care within the network, it costs less. Right. If you get care within the network of physicians that the insurance company contracts with, it costs less. But if you get out of network care, it costs more, but it is still covered. Cosmo, but it's still covered. Right. So obviously, if you have more flexibility, you're going to be paying more premiums than we see with a HMO. Right. So premiums are truly higher than we see with HM Os. Right. So PPO's, provider organizations, you don't use gatekeepers, right. They basically just pay providers on a fee for service basis. Right. Although many times, the PPO negotiates with these providers, you know, so they can get like these are contracted rates. All right. Now, the next one is Epo, right. Exclusive provider organization. We're not talking about the rate of point in here, right. But EPO, right. It's kind of a hybrid, right. You don't need a referral, right. So like a PPO, but they don't cover out of network care. Like we see with a HMO, right. Except for emergencies, right. So the premiums are kind of in between what you get charged with a HMO and a PPO, right. So think of it as a hybrid, right. It's like an in between, it's like an in between her, right.

You don't need referrals, but out of network care, they don't cover it, right. So it's more restrictive than a PPO, but it's less restrictive than a HMO, right. So the premiums are kind of in between a HMO and a PPO, right. And then another managed care plan is what we call POS, right. So point of service, right. So it's another hybrid, right. So there's a network, there's a PCP, you know, kind of like a HMO, right. But they allow you to, they allow, you know, out of network care, but you need to do higher cost sharing, right. It's kind of like a PPO, right. It's kind of like a PPO, right. So the PPO, the point of service care, right. Again, it's a hybrid. There's a network, there's a PCP, right. Like a HMO, but if you want to see somebody outside of the network, that's fine, but you're going to pay a bigger amount, you're going to have bigger copies and deductibles. All right. Next, let's talk about a high deductible health plan, right. High deductible health plan, right. So these plans have high deductibles, right. So, so for, you know, the essentially like you remember, we talked about the difference between deductibles and copies and whatnot, right. So your deductibles here are higher for the care that you receive. So you're like, why would a person want to do that? Well, the reason you want to do this is in exchange, you get lower premiums, in exchange, you get lower premiums, right.

So the thing is these high deductible health plans, one thing that is super high you to know about them for your exams is that we tend to pair them up with a with a HSA, with a health savings account, right. I mean, if you want to know, why would I want to do a health savings account? Well, the thing is it pretty much allows you to use pre-tax dollars, you know, save or pre-tax dollars, use it for qualified medical expenses, right. So like, for example, you can essentially deduct the amount of money that you put in a health savings account. You can deduct, you can deduct that as a personal expense when you're filing your tax returns, right. And the thing is if you don't use up the money for HSA, you can actually just roll it over from year to year, right. This is very, very different from an FSA flexible spending account, right. Flexible spending account is kind of like a use it or lose it. If you don't use it, you pretty much lose it for most of those funds, right. So the thing is, again, remember, for a health savings account, you must be enrolling a high deductible health plan, right. And again, the contributions can roll over. So people actually use this for some pretty good tax advantages, but I'm not going to discuss that here. That's well beyond the scope of the USMEL exams. I'm not a tax, tax accountant, right. But so, HSA, right. Again, you can roll the contributions, you put in, you can roll it over almost like in paper, two in a cent, right.

But again, we know that loss change all the time, right. And you're the one that owns the account. But compared to this with an FSA flexible spending account, right. It's pretty much available with any employer plan, right. Even if it's not a high deductible health plan, right. But again, it's use it or lose it, right. You know, these likely, they have slightly different expense rules and things like that. But again, that level of detail is probably not necessary for your, for your exams, right. And then one of the things I think I want to talk about from the health insurance landscape, again, this last podcast is just to kind of tee up some loose ends. You know, some quality metrics that occasionally you may see on your exams, right. Quality metrics, or you may see the term like utilization review, right. So let's kind of talk through these things, right. So the first one I want to talk about is is head is, right. He D I S, right. It's actually an example of a quality measurement, right. What does head is stand for? Well, basically, it means a health care effectiveness data and information set, health care effectiveness data and information set. Basically, this is a way to compare insurance plans apples to apples, right. Let me explain, right. So in fact, it's probably one of the super, super widely used, right. One of the most widely used, you know, set of quality measures in managed care, right. And it's maintained by an organization known as the NCQA, right.

The National Committee for Quality Assurance, right. What does it track? It tracks a bunch of metrics. So things like breast cancer screening rates, A1 C testing in the abedics, right. Childhood immunization rates, anti, you know, depression, medication management, right. And basically, like, it's like, hey, for this health insurance plan, what do the metrics look like for things like these for this other health insurance plan? What do the metrics look like for these, right. So the thing is, it basically helps you compare. Wait, this insurance plan versus this other insurance plan, like those these insurance is this insurance plan that's really with me getting my breast cancer screening, right. Do they have like pretty high breast cancer screening rates or A1 C testing rates in the abedics and things like that, right. It's a very good way to compare one insurance plan to another, right. So if they give you a broad question about how a health plan measures quality, a HADC is going to be the right answer, HEDIS, right. It can actually help you identify gaps in how well this plan is doing. And you know, it can help them, you know, kind of make changes, right. Kind of make make changes. Although you know that these insurance companies, they want to keep as much money as possible as much of the premium and do as little as possible, right. Again, any business is set up to make profits. All right. Now, another quality measure I want to talk about the money care plan, right.

Think of a QALY, a quality adjusted life here, right. Basically, it represents one year of perfect health, right. One year of perfect health. That is literally what what it means, right. And we tend to use it in cost effectiveness analysis, right. Because many times uh, and maybe maybe let me break that down a little bit, right. So QLY, right. Many times again, it represents again one year of perfect health, right. One year of perfect health, right. But you need to be careful because this is adjusted by a quality by a by like a quality score, right. So see, for example, if something gives you two years of life, but it gives you two years of life at 50% quality, then it's like, wow, okay, you're only getting one year of perfect health from those two years of life, right. Because if you're living two years at 0.5 quality for each of those years, then two times 0.5 is one, right. Or if something is giving you four years at 0.25 quality of life, four times 0.25, right. 25% quality of life, right. That's still giving you one year of perfect health, right. So the thing is the way it works, it's almost like a standardized way to see, uh, the effectiveness of an intervention, right. Like, hey, how effective is this? But again, we tend to attach a cost to it, right. In fact, many times when we're doing cost effectiveness analysis, we do this thing called a cost per QALY, cost per QALY, right.

Because it helps you compare like, hey, this intervention versus this other intervention, which one gives me the most QALY for the least cost, right, for the least cost, right. They like to, you know, test this in the context of like, you know, cost effectiveness analysis, bioethics, health policy questions, right. So, you know, many of these health departments, they keep these things in mind or these national organizations, they keep these things in mind when they're doing resource allocation, right. So it's a big time consideration when you're allocating a scarce healthcare resources. Remember, healthcare resources are pretty much always scarce. And then another quality metric I want to talk about is utilization review, right. So what in the world is utilization review? This is something that's actually beginning to pop up quite frequently on the US Emily exams, right. So it's basically a process that an insurance company is going to use to evaluate if care is medically necessary, right. Is the care medically necessary? Is the care appropriate, right. And it basically comes in in three forms, right. So there's like almost like the pre I like to think of it from a perspective of like almost like pre-rinal aka I intrinal aka I post-rinal aka I you're going to see what I mean as I go along, right. But the pre-rinal aka part of things or analogous part of things here is something called like perspective review, right.

If you've ever heard of prior off, this is what it is, right. Perspective review, right. Perspective utilization review is pretty much prior authorization, right. So the thing is you've got to get a approval from the insurance company before you get the service, right. This is actually pretty common for things like elective procedures or medications that are super expensive or like certain inpatient admissions is like, hey, the insurance company has to put their stamp on approval or need if not you're not getting that thing. At least they're not going to cover it. Now let's talk about the intrinal aka I side of things, right. Let's talk about the cally concurrent review, right. Concurrent review, basically the insurance company is keeping tabs on an inpatient state. They're like monitoring on an ongoing basis, right. The basically decide that hey, is this person's hospitalization justified, right. Should we keep this person in the hospital like for four days or for five days or whatever, so I truly keep monitoring things, right. And then let's go to the post-rinal aka analogy of things here, right. This is retrospective review, right. Makes sense, right. Retro in the past, right. So this is basically like reviewing claims after the fact, right. So insurance companies, they can review the claims after the fact and they can see you know what we're going to deny payments, right. You need me to start in criteria. We're not going to pay for this, right.

Again, insurance companies sometimes, again, they're beneficial, but they can sometimes be the being of a physician's existence, right. So the thing is prior off, prior authorization, right. Perspective review is one that they like to test quite frequently on the US similar exams, right. So they give you a question about a physician, right. You know, the vision wants to order an MRI for a patient that has back pain, right. But then the insurer is asking for for the medical necessity for this. This is basically a prior authorization question, right. So the thing is the physician typically will have to document like medical necessity, you know, submit the requests and then hope that insurance accepts it, right. But they can give you a question on your exams with insurer, says, hey, we're not going to cover this. We're not going to cover this. So they ask you on your exams, what's going to be the most appropriate next step or your most appropriate next step is to file an appeal, right. You need to file a formal appeal, right. And the thing is if it's something that the patient needs urgently, you can actually do an expedited appeal. You can do an expedited appeal, right. And then the thing is one thing you may see really doesn't pop up frequently, but really may pop up on an exam on an exam is something called the CON, the certificate of need, right.

The certificate of need, basically like some states, they actually require some hospitals, you know, or facilities to say, hey, this is the need, this healthcare facility will want to build. This is the community need for it. This is the community need for it. Right. So before you build a new healthcare facility or expand your current healthcare facility, right. You need to submit like a certificate of need in some states, right. It's kind of like a health planning tool, right, because you want to control costs, you don't want to duplicate services, right. Like if we already have enough healthcare facilities to serve a particular need for a community, why do we need to build a new one? Why don't we use those funds instead to build something else that is not currently present in that community, right. So certificate of need, right. So basically like again, you need to demonstrate need in some states, right. It's not it never stayed, but in some in some states. All right. Now I want to talk about some things that are kind of weird with regards to ethics and insurance, right. So, you know, there against some of these terms, you may see on your exams, right. So like a classic one, you may see is adverse selection, right. So adverse selection basically is like, oh, healthy people, they're like, nope, we're not getting insurance. Sick people, they're like, yes, we're definitely going to enroll for insurance, right. What do you think this is going to do in terms of premiums?

It's going to drive up premiums, right. It's going to drive up premiums. It can destabilize an insurance market, right. So this was part of the thing that the affordable care act was trying to deal with with the individual mandates where, you know, basically like everybody signs up for insurance, right. Because it kind of contracts adverse selection, right. Because it basically keeps healthy people in the pool. It makes sure that healthy people get insurance, right. But sick people also get insurance, right. To kind of counterbalance this adverse selection where it's like, wow, it's only sick people getting insured. Healthy people are not getting insured, right. And then another closely related concept to adverse selection is something called moral hazard, a moral hazard, right. So basically like it's like, hey, I have insurance. So I'm going to use more healthcare than I would otherwise, right. Then I would otherwise, right. Because hey, I'm this cost is being distributed. And paying my premiums, I better get as much healthcare as I can get, right. No, right. That's a moral hazard. It's like, wow, care that you orderly wouldn't get you're getting it basically because you're you have insurance, you feel like, okay, I have this blank check to use healthcare as much as possible, right. So how is this moral hazard courtailed, so again, the USML is they like to test these concepts in the context of hey, what can we do to kind of shot this down?

What can we do to kind of curtail this? Well, the thing is high cost sharing, right. So things like deductibles, things like copies, right. That's one very classic mechanism to counteract moral hazard, right. If you know that, hey, okay, I'm going to get this care that you typically would not get, but you notice that man, the deductible is pretty high. The copy is pretty high. That's probably going to make you think a little bit think twice before you start jumping on those things, right. And then again, remember, as a physician, you have an ethical duty to advocate for your patients, right. Within these constraints of managed care, right. You have an ethical duty to advocate for your patients, right. If if necessary, referral is denied, you need to you need to appeal. Right. Remember, your duty ultimately is to the patient, even if you're enrolling a managed care plan as a physician, right. Your ethical duty or fiduciary duties to the patient not to the insurance company, right. So just keep that in mind, right. And then just a few quick things on health disparities, right. Remember, right. Again, they love to test this on the exams, right. It's classic, yes, any of the bots father, right. But basically remember, people that are on insured, right. They are more likely to be in minority groups, right. Blacks, Hispanics, right. Low income people, immigrants, right. Or residents of these are ACNON expansions.

These remember I talked about what the expansion means in an earlier podcast, right. So, and the thing is if you don't have insurance, you're going to get delete diagnoses, you're going to get worse outcomes in pretty much every chronic disease, right. You're going to have much higher rates of preventable hospitalizations, bigger utilization of emergency rooms, right. So just things to keep in mind for your exams, right. And then they also like you to know about the social determinants of health, right. Again, the USMEL is the one to essentially be able to connect insurance status, you know, from, you know, like a brother social context, right. So the thing is a person that is on insured, a person that doesn't have health insurance, that's usually not the only problem that they have, right. They may have food insecurity, they may not have access to food, right. They may live in a food desert, right. They may have like housing instability, they may have like transportation barriers, right. That basically prevent them from assessing care, right. Because think about it, if you need to go and visit a doctor, but you don't have transportation to get there, how you're going to get there. Literally, how you're going to get there, right. Or if you are homeless, right. Again, it may make it difficult for you to go to a doctor's office, right. To go to a doctor's office, right. So the thing is, again, they can give you questions like these, I revolve around these concepts, right.

And they ask you, hey, what's the most appropriate next best step in management, right. And the answer may be doing things like, you know, connecting the patient to a community health center or referring them for a food assistance program or referring them for transportation services, right. Not just prescribing medications, right. Not just prescribing medications. And again, remember this thing about like the nutrition programs like WIC and SNAP and what I talked about that in the nutrition podcast. All right. Now, how about a fair, an FQHC? What in the world is an FQHC a federal qualified health center, right. So they love to test this on the exams, right. Basically, it's a, it's a health center that serves patients regardless of ability to pay regardless of your ability to pay, right. And they use like a sliding fee scale, right. So the more money you make, the more you pay, the less money you make, the less you pay, right. And the thing is these FQH Cs, they tend to get kind of better reimbursement from Medicare and Medicaid, right. There's literally like federal laws, right. That's why they're called federally qualified. You have to be qualified to receive this kind of reimbursement, right. So if they give you a question about a kind of clinic that serves, you know, an on like on insured, low in competitions on the USM, the exams pick the answer that talks about an FQHC, right. Pick the answer that talks about a federally qualified health center, right.

And then don't forget him, Tallah, right. Emtallah is another concept you want to know for your exams, right. Is the emergency medical transport and active labor act, right. Emtallah, right. Basically, what is the key thing? What I'm not about, Emtallah. If you have any hospital that has an emergency room that received, that receives Medicare funding, you must screen anyone that presents anyone that presents, right. Regardless of the insurance, regardless of the ability to pay, right. And you must stabilize a person that has an emergency condition. They got to get stabilized, right. And then all you need to transfer appropriately, right. So Emtallah doesn't guarantee that, hey, you're going to get all the care you need. No, he just guarantees that, hey, you present to an emergency room that is that receives that gets reimbursement with Medicare, you need to get civil rights, right. So again, a hospital cannot turn away a patient in labor, right. And they will use a specific scenario on your exams, right. They're not just going to use like a small definition. No, they're going to give you a question about a patient that is in labor, right. Or a patient that has an acute MI, and the person is on the insured, and the person presents to an emergency room. The emergency room cannot turn that patient away. You need to take care of the patient using to stabilize them or transfer them as appropriate, right.

And one thing to know about Medicare, that you know, you should probably just keep in mind for your exams, and also just for clinical practice, honestly, right. Is the two, although remember, this podcast is not for clinical practice, it's just to give you tips, okay. Give you tips on, for example, that's my primary go with this podcast here. But the thing is, there's this thing called the two midnight rule, right. Basically, Medicare is going to be for inpatient hospitalization, right. When the physician essentially expects the patients to spend two or more midnight in the hospital, right. So if you admit a patient, and they end up staying less than two midnight, Medicare actually reclassifies it in many cases, right. They reclassify it as an outpatient observation state, right. And that has very different coverage implications, right. Very different coverage implications, right. So you're just going to keep this at the back of your mind, right. That two midnight rule is kind of important, right. Kind of important, right. So again, remember across this podcast series, we've talked about many things, right. We talked about Medicare and how again, it's mostly for people over 65, or if you're going to be social security disabled for like 24 plus months, right. We have ESR, the ALS, right. We talked about part A with, you know, inpatient state, hospital state, part B with, you know, outpatient, you know, visits, parts C Medicare advantage, part D with prescription drugs, right.

Remember, Medicare doesn't cover costotal care, right. And again, to be admitted to for Medicare to pay for skilled nursing facility, you need to have been in the hospital for three days, right. Remember, Medicaid is like a joint program between the feds and the states, right. You know, covers low income groups, right. Covers long term costotal care, right. So keep that in mind, right. And they remember chip, right. The Children's Health Insurance Program, right. For kids up until 2019, right. Many times you're going to see this with families that are, you know, the they make too much money to be eligible for Medicaid, but they cannot afford a private insurance, right. And they remember in the previous podcast, I talked about payment models, right. You know, fee for service, computation, diagnosis related groups, account book organizations, you do need to know those things, right. And then in this podcast, I've talked about like hate, you know, HM Os, right. The different money care plans, right. HM Os, PP Ls, PP Ls, right. How did that to high deductible health plans, health service accounts, flexible spending accounts. You've got to know these things for your exams, right. You know, HADS measures, QL Is, utilization review, right. The different kinds. Remember the pre-insurance and post-RINAL EKI analogy that I use, right. Talk about him, Tallah, right. So just make sure you know these things, right. They love to test them on the exams, right.

They love to test them on the exams. And many times these things are you either know it or you don't. If you know it, you'll get the question right. If you don't know it, you're screwed, right. So don't be screwed on your exams. And if you love the way I teach, you've got to love the classes that I teach, right. So starting the middle of this month, the 15th basically, I have a bunch of classes that are very helpful for step one, two, three, right. So like third week in this month, I begin with a CCS class, right. As they're three CCS class, I mean, it's a one hour class. And then I have a, and that's just for step three, right. And then for step one, two, step three, I have a biostatistics class that's four hours long, a social sciences and ethics class that's five hours long, right. And again, many, and a test taking strategy class that's two and a half hours long, right. Many people take these classes and find them to be really, really helpful, right. And they're all over Zoom. And again, it's not me giving a lecture. It's me using questions and practice problems to teach you concepts, to teach you content, teach you strategy, right. And then for step two and step three, specifically, I have a last mini review, that's three hours long. Oh, so many people love that class, right. And then I have a 20 hour step two, step three class that again, a lot of people have taken on phone to be extremely helpful.

I've literally had people get as high as two eighties from taking my, my review classes, my 20 hour step two class, my 50 hour step two step three class, right. And then I have a 25 hour step one review, ready for bookticking step one, or people that have poor foundations, poor basic science foundations that are taking step two or step three, right. So thank you for listening to me in this podcast. Also, if you're one of one to learn for all the USML and complex exams, I have my podcasts on Apple Google and Spotify. I have a You Tube channel as well, where I post the podcasts that I make, right. And remember, I also help with era's applications, personal statements, mocking reviews. I help with application edits and things like that. And then I have another website known as a Divine Intervention Live Lessons.com. Divine Intervention Live Lessons.com. Every week I post like one podcast, we're from a biblical perspective address, a life lesson. There's actually an Apple podcast associated with that called the Divine Intervention Live Lessons podcast. Many people actually listen to it every week, have like 400 podcasts on there and I keep adding more and more new ones every, every single week, right. So thank you for listening to me today. I will see you got really in a episode 659, right. I can't wait for the day where Divine Intervention podcast gets to a thousand, I guess we'll see. We'll see. All right. So have a wonderful day. God bless you and our bye for now. Thank you.

It requires members to choose a PCP who acts as a gatekeeper and must provide referrals for specialist care; generally does not cover out-of-network care.

A PPO is more flexible, allowing the patient to see any provider in or out of network without needing a referral (though it costs less within the network).

HS As allow contributions to roll over from year to year, whereas FS As are typically "use it or lose it."

Prospective review, which is synonymous with prior authorization—requiring approval before a service is received.

Adverse selection.

Federally Qualified Health Center (FQHC).

It measures healthcare effectiveness data; it is maintained by the National Committee for Quality Assurance (NCQA).

A Quality-Adjusted Life Year; it represents one year of perfect health and is used to compare interventions based on cost-effectiveness.

Prospective (prior authorization), Concurrent, and Retrospective.

EMTALA (Emergency Medical Transport and Active Labor Act).

High cost-sharing mechanisms, such as high deductibles and copayments.

The patient must be expected to spend two or more nights (two midnight rule) in the hospital.

It measures healthcare effectiveness data; it is maintained by the National Committee for Quality Assurance (NCQA).

A Quality-Adjusted Life Year; it represents one year of perfect health and is used to compare interventions based on cost-effectiveness.

Prospective (prior authorization), Concurrent, and Retrospective.

EMTALA (Emergency Medical Transport and Active Labor Act).

High cost-sharing mechanisms, such as high deductibles and copayments.

The patient must be expected to spend two or more nights (two midnight rule) in the hospital.