Term
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Definition
| An organized effort by health insurence plans to use the financial incentives/organizational arranegements to alter provider/patient behavior so that health care svs are delivered and utilized in a more efficient and lower cost manner. |
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Term
| What are the 7 objectives for Managed Care? |
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Definition
1)Enhance cost containment
2)Implement some forms of rationing
3)Promote administrative and clinical effiiency
4)Reduce duplication of services
5)Enhance appropriateness of care
6)Promost aomprehensive contrasting mechanisms
7)Manage care processes by managing provider and consumer behavior |
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Term
| Whats the big deal about Managed Care? |
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Definition
-transformed health care
sucessfull (beacause of ffs failures and uncontrolled costs)
-long term ability to control costs may be in question
-enormous buying power. EMployees are active purchacers of health ins
-organization integation - new types of HC organizations |
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Term
| What is meant by MCs integrationof the quad functions? |
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Definition
Integrate Quality/Access/Cost Functions:
• Financing: Financial risk is spread; financing is spread contractually between employers and MCOs
• Insurance: MCO assumes risk, eliminates need for separate insurance company; risk is shared with providers
• Delivery: comprehensive array of services contracted with providers
• Payment: capitation (patient: fixed copayments no deductibles; provider: paid fixed monthly sum per head), discounted fees, salary. Premiums are calculated on previous medical history in aggregate; as medical costs increase, premiums increase…a lot |
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Term
| What are the 3 main types of payment under Managed Care? |
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Definition
- Capitation
- discounted ffs (pre-negotiated fee schedule)
- salary (+witholdngs, bonuses)
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Term
| What is the benefit to capitation in MC to the provider? |
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Definition
That there is a paide fixed monthly payment PMPM=per member per month
-regardless of wheather or not the enrollee uses the survaces. |
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Term
| What is the Medical Loss Ratio |
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Definition
-The proportion of premium that an insurer must spend on medical care.
-ACA mandates that the MLR is 85% |
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Term
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Definition
HMO=Health Maintenance Organiszations
Members recieve all medical care through one group of providers.
Physicians recieve a fixed fee per member, per month
Members have low deductables and copays |
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Term
| The nature of the HMO shifts the responsibility to the _________ |
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Definition
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Term
| What are the defining features of the staff model |
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Definition
Employs its own physicians
Physicians are salaried members of large corporations
hospitals, clinics and other institutions are owned by the corporations. |
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Term
| What are the defining features of the group model |
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Definition
The physicians coose to become formal member od an organized medical groups
Medical groups practice together
formal contract is between the group and the HMO |
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Term
| What are the defining features of the network model |
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Definition
A group of independent practice physicians who collaborates to take part in large contacts with HMOs
Physicians recieve the benefits of independence, mult sources of patienst and other contracting arrangements |
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Term
| What are the defining features of the network model |
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Definition
Can comprise of some or all of the features of the other models.
It can have solo practictitioners, hospitals, the HMO takes care of the marketing, billing, collection etc. While practitioners provide care. |
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Term
| What are the two largest HMO model types? |
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Definition
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Term
| What are the dfining features of a PPO? |
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Definition
PPO=Prefered Provider Organizations
A fee for service health plan
-allows beneficiaries to obtain care from providers who have given th eplan a discount,
The share of cost for members is substantially reduced if they choose providers within the network |
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Term
| What are the defining features of the POS plan? |
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Definition
Combines elements of HMO PPO
usually 3 choices for health care:
-HMO
-prefered providers
-outside POS
higher cost sharing for members who go outside the hMO or preferred group |
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Term
| What did the balanced budget act allow the states to do with Mcs 1997? |
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Definition
BBA=Balanced budget act-1997
Allowed states to enroll Medicaid members in MCs.
70% beneficiaries are in managed care
however, BBA reduced capitation and MC and lead to MC pullouts.
In 2003 MMa added funding for medicare advantage (24% of beneficiaries are in MC)
Payments to MA wil be reduced under the ACA of 2010 |
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Term
| What are the 3 main reasons for MC backlash in 1990s? |
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Definition
1) employers faced barriers to free choice of providers
2)Employees did not see lower out of pocket costs
3)Physicians reacted negatively to utilization and lower reimbursement |
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Term
| How is physician behavoir influenced in MC? |
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Definition
1)feedback and comparasons to the norm with quantitative data
2)socialization to group goals and philosophy
3)physician recruitment and selected contracting prolicies
4)positive rewards such as call preference, rewards and benfits
5) promotion of team work and quality management
6) |
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Term
| What are the 6 cost controls in MC? |
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Definition
1)choice restrictions
2)Gatekeeping
3)Case Management
4)Disease management
5)utilization review
6) practice profiling |
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Term
| How does Choice restriction control costs in MCs? |
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Definition
Formal affiliation of physicians
Lack of choice is found to be the greatst source of dissatisfaction with health plans among enrolless in research |
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Term
| How does gatekeeping control costs in MCs? |
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Definition
| On physician provides all primary care for patient and controls patient initiated use of specialist - triage |
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Term
| How does Case management control costs in MC? |
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Definition
oragnized approach
Coordinating care
(especially for pts who have complex issues)
-highly individualized
-too much work for PCP gatekeeper |
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Term
| How doesw disease management control costs for MC? |
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Definition
population oriented stratigy with those with specific chronic conditions
education, training on self-management, ongoing monitoring and followup
goal of reducing/preventing complications |
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Term
| How does utilization review control costs for MC? |
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Definition
evaluates appropriateness of services
-prospective
-concurrent
-discharge planning |
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Term
| How does practice profiilng control costs in MC? |
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Definition
| Examines physician specific practice patterns |
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Term
| What are the issues sourding MC and conflict of interest? |
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Definition
1)The need to minimize services
2)medical ethics vs economic pressures
3)Patients who need specific services may not get them in the future |
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Term
| What are the trend concerning QAC with MCs? |
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Definition
Q: NCQA started accrediting MC plasn in 1991 - addresses conflic of interest issues
A: generally good aces to services, pts just feel like lack of choice and no cost benefit
C: initial cost savings but not clear if further reductions and savings are possible |
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Term
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Definition
| Accountable Care Organization: an integrated group of providers that takes responsibility fo rimproving the overall status of a defined population |
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Term
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Definition
A ophysician hospital organization:
groups of physican band together with local hospitals to provide all care to enrolled patients
no insurenece or health plan directly involved
-maintains more control over medical decisions - but what about if they cannot provide care directly? |
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Term
| What is an integrated delivery system? |
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Definition
A network of organizations
clinically and fiscally responsible
coordnated continum of services
SHARP, mercy, sutter |
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Term
| What is consolodation in general models of integration? |
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Definition
| concentration of control, consolodation of existing assests |
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Term
| What is expansionin general models of integration? |
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Definition
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Term
| What is diversification in general models of integration? |
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Definition
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Term
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Definition
| A joint venue is an entity formed between two or more partues to undertain an economic activity together. (etc) |
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Term
| What is horizontal integration? |
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Definition
A type of integration, where services are similar or subtituted
to control geographic distribution |
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Term
| What is vertical integration? |
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Definition
A type of integration where serviuces are diversified
-branch out in to new serviec areas |
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