Term
| STATE OF HEALTH CARE-NEW MILLENNIUM |
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Definition
| INCREASES IN COSTS TO DOUBLE DIGITS, HEALTH CARE EXP-LARGEST SINGLE NO WAGE COST, PRIVATE & PUBLIC FORCED TO EVALUATE MANAGED CARE PLANS |
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Term
| ECONOMIC PRESSURES IN NEW MILLENNIUM |
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Definition
FEDERAL GOV'T COST SHIFTING--
OVER 65 MUST SELECT MEDICARE OR EMPLOYER'S PLAN AS PRIMARY MED COVERAGE
COMPETITIVE GLOBAL ENVIRONMENT--EMPLOYERS BEAR MOST OF COST IN U.S. ONLY
SHRINKING WORKFORCE--TRAINED LABOR
NATIONAL SPENDING ON HEALTH CARE--LESS SPENT IN OTHER AREAS
HEALTH CARE COST TRENDS-DROP IN EARLY 90'S, NOW INCREASING-FINANCIAL BURDEN |
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Term
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Definition
| FROM INDEMNITY(10%+/-) TO HMO-30%, POS-16%, PPO-FROM 11% TO 43% (YR 2000) |
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Term
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Definition
PROVIDED FED INITIATIVES TO ESTAB HMO'S, FEDERAL GRANTS AND LOANS TO ORGAN.
HMO GROWTH BEGAN AFTER PASSAGE THEN WITHDREW IN THE 80'S, BY 1998 CORP HMO'S CHAINS AND NAT INSURANCE CO OWNED 3/4.-85% ENROLLMENT |
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Term
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Definition
| Sponsored by nat insurance co., TPA, BCBS, Hosp, and Benefit Conculting, as alt to compete with HMO's in the 70's and 80's-saved cost but not cjoice as with HMO |
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Term
| PPO Savings problems/solutions |
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Definition
-Primarily fee-for-service and no utilization comtrol
-Changed to incr monitoring, QC and member survey
-Argue that PPO's weak form of managed care-rich benefits and more exp than HMO's |
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Term
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Definition
Intergarated treatment method that a patient receives, may have some financial risk and responsibility, particular benefits, quality of care, and patient initiatives.(A Process)
Includes managed indemnity plans, HMO,PPO,POS-intended to influence & direct the delivery of HC by plan design features, access restricted to preselected providers, and Utilization management |
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Term
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Definition
| Directs members to in-network providers by setting benefit differentials between 10-30%-steers members to contracted providers. |
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Term
| Managed Indemnity(UM) plans vs traditional |
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Definition
Not with Traditional
Precertification of admissions
Concurrent review
Discharge planning
Precert outpatient services
Second surgical opinion
Case mgt for high dollar cases |
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Term
Deductibles
Coinsurance
Explain |
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Definition
Deductibles & coinsurance should keep pace with inflation.
If low ded-does not encourage prident use.
Coinsurance usually 80% to certain limit then 100% for cal yr. |
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Term
| Incentive/Dis for design of PPO Plan |
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Definition
Incentive-Least employee disruption-richer preferred benefits (100% vs 80%)
Disincentive-Objective is cost(80%/60%) savings,nonpreferred benefits % lowered.
Combo-Some improvements and saves money-(90%/70%)
---Must be a greater differential in POS plan--- |
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Term
| Key Component of POS Plan |
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Definition
| PCP "gatekeeper"to specialist care |
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Term
| POS plan features to encourage care through within network through PCP |
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Definition
| No deductible, preventive services, 1-GYN exan/yr, no claim submission, PCP obtains necessary precert for hospital |
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Term
| Key distinction in level of coverage for HMO, PPO, and POS plans |
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Definition
HMO-No coverage outside of HMO unless Emergency,
PPO/POS can go out of network but benefits at a reduced rate |
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Term
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Definition
NO annual deductible and small copay
Preventative services through PCP
1-GYN per year
No claim submission
PCP obtains hosp pre-cert |
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Term
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Definition
Group-Group of physicians
Staff-Like Group but physicians employed by HMO
IPA-Individual practice associations |
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Term
| Factors of Managed Care vs Traditional fee-for-service plans |
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Definition
Degree of freedom, degree of steerage
claim handling, external util control, referral mgt, provider reim methods, patient-balance billing, rating-financial methods, expected net savings |
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Term
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Definition
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