5 - Managed Care Flashcards
Managed Care
COMBINES the functions of:
Health Insurance + Financing + Actual delivery of care
involves risk sharing of
delivery health services + deined network of providers
influences utilization + cost of services and measures the QUALITY OF PERFORMANCE
How does MANAGED CARE control
Costs + Service Utilization?
GATEKEEPING
Responsible for the admin of a patients treatment
CARE MANAGEMENT
Care coordination:
ensure EVERY PERSON served by the system has a single approved care / service plan that is coordinated within prescribed parameters
UTILIZATION REVIEW
Process to review decisions by providers on how much & what type of care to provice
Managed Care 3 Principles
Managing the care of the patients
using a SELECT GROUP of health care providers
placing PROVIDERS @ Risk financially
Major Types of
MANAGED CARE ORGANIZATIONS
MCOs
HMOs = Health Maintenance Organizations
PPOs = Preferred Provider Organizations
POS Plans = Point of Service Plans
HMOs
type of managed care plan
Health Maintenence Organizations
Integrates financing + delivery of comprehensive healthcare services to members
Pre-determined pay / fixed premium, regardless of utilization
PCPs = GATEKEEPERS
4 Major Types of HMOs
Staff / Group > Network > IPA
models
Staff Model HMO
HMO employs ITS OWN PHYSICIANS + HCP’s
Staff work in clinical facilities usually owned by the HMO
Services are provided EXCLUSIVELY to HMO plan enrolees
Centralized locations:
primary care / pharmacy / lab testing
- *Closed-Panel Model**
- there are some exceptions, like ambulence fees or out of state emergencies*
GROUP Model HMO
Contracts with a LARGE MULTI-SPECIALTY physician group to provide near exclusive care to HMO enrolees
Physicians are employed by the group practice, not the HMO
HMO reimburses on capitated bases
NETWORK Model HMO
HMO contracts with MULTIPLE Physican GROUPS to provide services to HMO members
non-exclusive contracts are made by the HMO with large medical groups in the network
HMO enrolees comprise a small part of any one** network physician’s **group’s practices
IPA MODEL HMO
Individual Practice Associaition
(Independent)
IPA plan wherby physicians in solo private practice** or **small medical groups can join the IPA
IPA = LEGAL ENTITY, that functions as a intermediate organization representing INDIVIDUAL physicians / small groups
PPOs
Preferred Provider Organizations
Insurers contract with a panel of Participating Providers tohat provice services to enrollees:
Discounted Fee-For-Service Reimbursement
EPOs = Exclusive Provider Organization
form of PPO in which NO coverage provided outside the provider network
Point-Of-Service
PLAN
HMO + PPO HYBRID
allows the covered person to CHOOSE / RECIEVE a serice from a participating or nonparticipting provider
Must choose IN-NETWORK PCP
do NOT consfuse with POS SYSTEM, an electronic claims submission system used in pharmacy networks
HMOs = Health Maintenance Organizations
PPOs = Preferred Provider Organizations
POS Plans = Point of Service Plans
Pharmacy-related ISSUES
under Managed Care Environments
Prescription drug sales covered under managed care and subject to direct + indirect cost controls such as:
formularies / discounted fees / volume discoutnt / rebates / drug switching & generics
Need to manage the pharmacy benefit
PBMs
Pharmacy Benefit Managers
assume admin functions in managing pharmacy benefit and containing costs for health plans
Promote optimal patient outcomes by:
establishing guidelines for safety/efficacy/quality/cost
MIDDLEMEN or intermediates between customers
RX coverage / pharmacies / manufacturers / 3rd party payers
PBM Characteristics
THIRD PARTY ADMINISTRATOR
Pharmacy Benefit Manager
Administer drug benefit coverage of health plans on behalf of plan sponsers = gvmt / insurance / MCOs / rx drug plans
SEEK LOWEST COST from manufacturers and discounted prices from pharmacies
Similar to managed care, have a provicer network
