PHSC 2 Lecture Notes - Lecture 5: Utilization Management, Community Rating, Risk Assessment
7 Feb 2020
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Document Summary
Dec 2017 tax reduction legislation removed penalty for not having health insurance, effective 2019. Removed incentive to buy insurance if not covered by employer. Premium = amount charged by the insurer and paid by an employer, employee, or insured (self) and made up of: Risk assessment of population to be covered = process of modeling & calculating expected expenses of insured group. Administrative costs: marketing, contracting, claims processing, utilization management, quality assessment, legal & regulatory functions. Profit: favorable loss ratio (ex: minimal payout to providers) and high retention rate for insurance company. Individual or insured group"s medical claims history is predictor of future use of health care services. Varies by demographics, employment sector, geographic location. Spreads risk and bases rates on an enter community"s health profile & insurance claims history and likelihood of an event occurring in that population. Not limited to one employment sector or demographic.
