9 managed care and integrated organizations

Question 1

managed care

Answer 1

an organized approach to delivering a comprehensive array of health care services to a group of enrolled member through the efficient management of services needed by the members and negotiation of prices or payment arraignments with providers

Question 2

HMO act of 1973

Answer 2

didn’t really take off until the 1990’s when they transformed the delivery of health care

Question 3

capitation

Answer 3

a set of fees that practitioners are payed for for each enrolled person assigned to them

Question 4

managed care risk

Answer 4

MCO’s used shared risk
promotes delivery of health care that is economically prudent
preventative strategies lower cost

Question 5

medical loss ratio

Answer 5

the% of premium revenue spend on medical expenses the remainder is used for:
administration, customer service, marketing and profits

Question 6

ACA medical loss ratio

Answer 6

set at 85% can only spend 15% on other things if they

Question 7

flaws in fee for service

Answer 7

uncontrolled utilization, prices and payments

focuses on illness rather than wellness

Question 8

choice restriction

Answer 8

cost control method that avoids over utilization of services by setting restrictions on where and who you can get services from

Question 9

prospective utilization review

Answer 9

determines the appropriateness of utilization before the care is actually delivered

Question 10

concurrent utilization review

Answer 10

determines on a daily basis the length of stay necessary in a hospital, monitors use of ancillary services and ensures that the medical treatment is appropriate and necessary

Question 11

retrospective utilization review

Answer 11

after services have been delivered

Question 12

practice profiling

Answer 12

also called profile monitoring

- development of physician specific practice patters and the comparison of individual practice patters to some norm

Question 13

HMO’s

Answer 13

helath maintenance organization

• PCP is gatekeeper
• most common type until 70’s
• triple option plans
• required to choose PCP from panel in-network
• specialty services are carved otu

Question 14

HMO staff model

Answer 14

physician works for them

makes more money based off of how productive/cost effective they are

Question 15

HMO group model

Answer 15

group practice can have contracts with other MCO’s

Question 16

HMO network model

Answer 16

several group practices not as cost effective with utilization control

Question 17

independent practice association

Answer 17

group independent providers contract with IPA and then HMO contracts with IPA
middle man that creates buffer

Question 18

PPO

Answer 18

preferred provider organization
discounted fee arrangements with providers
out of network
exclusive provider plan
PCP not employed prior authorization is generally employed only for hospitalizaton and large out patient procedures
very common today

Question 19

what is the most common MCO today

Answer 19

PPO

Question 20

point of service plan

Answer 20

hybrid plan
cross between HMO and PPO
not very common today peaked in the 98/99