Ch. 4 Working in Today’s Health Care Environment Flashcards
1
Q
MCO
A
- Managed Care Organization (MCO)
- Gatekeeper— Primary physician
2
Q
HMO
A
- Health Maintenance Organization (HMO)
- Offers a wide range of services to members for a predetermined fee by a limited group of providers
- Capitation rate
- Offers a wide range of services to members for a predetermined fee by a limited group of providers
3
Q
PPO
A
- Preferred Provider Organization (PPO)
- Patient must use a medical provider who is under contract with the insurer for an agreed-upon fee
- Copayment
- Patient must use a medical provider who is under contract with the insurer for an agreed-upon fee
4
Q
EPO
A
- Exclusive Provider Organization (EPO)
- Combines the concepts of HMO and PPO
- Modified fee for service (FFS)
5
Q
Medicare..
A
- Health care coverage for elderly or seriously disabled, or with end-stage renal disease, or other debilitating ailments, regardless of wealth or income
- Rationing of health care
6
Q
Problems with Medicare:
A
- High cost and deductible
- Not accepted by all doctors
7
Q
DRGs
A
- Diagnostic Related Groups (DRGs)
- Classifies each medicare patient by illness into a category
- Hospitals receive a preset sum for a treatment of an illness category
- Regardless of “bed days” used
- Discourages treatment of severely ill patients
- Patients often are discharged before ready
8
Q
Medicaid
A
- For the poor and indigent
- A joint Federal-State program
- Federal government pays 57% of expenditures
- Federal program implemented by individual states
- Rationing takes place
9
Q
Problems with Medicaid:
A
- Not all providers accept Medicaid coverage
- Individual states enact their own legislation regarding spending
10
Q
Ethical Considerations of Managed Care
A
- Some physicians will not treat Medicare patients
- Must provide minimum standard of care to everyone
- Patients must be fully informed of consequences of obtaining health care elsewhere
- Bait-and-switch— Not all cost are covered
- Profit may be more important than patient’s health
- Wealthy may have greater access to care and treatment than poor patients
11
Q
Health Care Quality Improvement Act (HCQIA) of 1986
A
- Passed out of concern about medical malpractice
- Protects whistleblowers
- National Practitioner Data Bank (NPDB)
- Information not disclosed to general public
12
Q
Solo Practice
A
- Sole Partnership
13
Q
Partnership
A
- Share responsibility for financial and legal matters
14
Q
Associate practice
A
- Share facility, but not accounting or legal responsibility
15
Q
Group practice
A
- Three or more physicians
- Share same facility
- Practice medicine together
- Can be designated as HMO or IPA
