CH 12 (Managed Care)

Question 1

Define “managed care”. [2.5]

Answer 1

Managed Care aims to manage claim costs✓ while maintaining or even improving✓✓ access to quality healthcare services.✓

The system integrates the delivery and financing of healthcare✓✓ by providing the insurer with some control over the healthcare SPs✓ through tools such as provider networks, care coordination and evidence-based treatment protocols✓✓✓.

Question 2

Describe the role of managed care. [1]

Answer 2

The role of managed care is to achieve a balance between keeping HC affordable✓✓, but also ensuring the quality of HC remains of a high standard.✓✓

Question 3

What are the objectives of managed care interventions? [2.5]

Answer 3

• Reducing the cost of medical events.✓✓
• Reducing the number of unnecessary medical services.✓✓
• Ensuring that medical services are delivered in an appropriate setting.✓✓
• Improving the quality of care provided.✓✓
• Ensuring that high-risk members are managed and receive appropriate care.✓✓

Question 4

Describe how MC may result in an increase in cost of claims over time. [1.5]

Answer 4

There is a tendency for those covered by PMI to demand that the best healthcare services available are offered to them, whatever the cost may be.✓✓✓
This is exacerbated by the highly emotive aspect of healthcare, esp. for family members.✓✓
Very expensive treatments pose a risk to insurers if they are demanded by more and more PHs over time.✓✓

Question 5

Define treatment protocols together with four examples. [4.5]

Answer 5

It is a set of guidelines✓ setting out the optimal sequencing of diagnostic testing and treatment for specific conditions.✓✓
It is important that MCOs collaborate with recognized medical specialists ✓ to develop credible and recognised protocols✓✓, based on clinical best-practice.✓ CBP
Examples –
* A restrictive formulary governing which medicines (likely to be mainly generic medicines)✓ may be used for certain conditions.✓✓
* A requirement for a GP referral to be obtained prior to visiting a specialist.✓✓
* Restricting access to a select network of specialists and GPs✓✓, with whom preferential charging structures have been agreed.✓✓
* Maternity program✓ – only allowing caesarean section where these are deemed clinically necessary by a HCP✓✓

Question 6

State the disadvantages of treatment protocols. [3]

Answer 6

Given the extremely complex nature of healthcare and vast diversity of diseases that exist✓✓, it is most likely that 1st time PHs will come to know the relevant protocols of their insurer is at the time of claiming for a certain condition.✓✓
Many of those who have a claim declined✓, or having to make use of an alternative medicine or treatment than they would preferred, will be aggrieved.✓✓
Protocols need to be updated continually, as new medicines and treatments become available due to technological advances, as well as new diseases emerging over time.✓✓✓
Very restrictive formularies and protocols may actually restrict access to quality healthcare.✓✓

Question 7

List the measures that may be used in order to assess the quality of care. [1.5]

Answer 7

Patient mortality rate ✓
Specialist referral rate ✓
Procedure complication rate ✓
Hospital admission rate ✓
Patient questionnaires ✓
Chronic medication adherence ✓