1.8 Cost Containment Principles Flashcards
Traditional insurance uses cost containment strategies in the form of?
1.
2.
3.
- Coinsurance
- Co-payments
- deductibles
Is a set amount the patient pays each time a specific service is rendered.
co-payment
is a specific amount of money the patient must pay for covered expenses before the insurance company begins paying.
Deductible
There are 2 main types of managed care organizations.
1.
2.
- Preferred Provider Organizations (PPOs)
2. Health Maintenance Organizations (HMOs)
This type of managed care organization contains cost by negotiating discounts for services with providers as a condition for being included in this type of managed care.
Preferred Provider Organizations (PPOs)
This type of managed care organization provides healthcare services to members for a set yearly fee per member. (often use PCPs as gatekeepers and emphasize preventative care)
Health Maintenance Organizations (HMOs)
Medicare implemented the ___ ____ ____ system, in which a fixed amount is payed for a given diagnosis, rather than paying all costs related to an individual patient’s treatment during his or her hospital stay.
Diganosis Related Group (DRG)
Is a system of healthcare delivery whose goal is to maintain quality, cost-efficient care by managing the use, access, cost, quality, and effectiveness of services.
Managed Care
PPOs contract with providers to deliver care at a discounted rate. The providers with whom they contract are considered “_____ ______.”
network providers
This organization is similar to a PPO in that a network of providers have agreed to provide care for the members at a discounted rate. In this organization, however, a patient is not reimbursed for services if he chooses to receive healthcare outside of the network.
Exclusive Provider Organization (EPO)
This plan is a combination of PPO and HMO. The patient can choose to receive care at in-network at little or no cost, or to go out-of-network and incur larger out-of-pocket expenses.
Point-of-Service
Services that are not included in the contract between the provider and the HMO can be “___ ___” services.
carve out
HMOs often use PCPs as what?
Gatekeepers
4 types of HMOs: 1 2 3 4
- Group Model HMO
- Network Model HMO
- Individual Practice Association (IPA) Model HMO
- Staff Model HMO
this model HMO contracts with a multi-specialty physician group, where the physicians are employed by the group, not the HMO
Group Model HMO
this model HMO is similar to the group model but involves more than one group of physicians.
Network Model HMO
This HMO model contracts with physicians who provide healthcare to the HMO members for a negotiated rate. They own there own practices.
Individual Practice Association HMO model
In this HMO model physicians are employed by the HMO and provide services exclusively to members of the HMO.
Staff Model HMO
