Chapter 2 Flashcards
Chapter 2 Vocabulary and info
Allows coordination among providers, monitoring of quality, and identification of superior or cost-efficient providers as well as inappropriate use.
utilization review
Organized healthcare systems responsible for both financing and arranging the delivery of a broad range of health services to a defined population.
health maintenance organizations (HMO)
Entities through which employer benefit plans and health insurance carriers contract to purchase healthcare services for beneficiaries from a selected group of participating providers.
preferred provider organization (PPO)
A legal entity of independent physicians who contract with the IPA with the sole purpose of having the IPA contract with HMOs.
independent practice association (IPA)
Organization of physicians who are not dependent on a hospital for services or support. Owned and governed by physicians. Practice aggregated into a legal entity, but still have independent locations.
group practice without walls (GPWW)
True group practice. Combined assets and risks but physicians remain in their own offices.
consolidated medical group (CMG)
Business entity that allows a hospital and it’s physicians to negotiate with third-party payers.
physician/hospital organizations (PHO)
Tax-exempt organizations (i.e. hospital) creates a non-profit foundation that purchases and operates physicians’ practices.
foundation model integrated delivery system
i.e. St. Mary’s Hospital Foundation
Medicare and Medicaid programs required these programs starting in 1966.
utilization review
Act of 1973 that was an effort by congress to address quality and cost of health care.
Health Maintenance Organization Act of 1973
Managed care includes:
- preferred provider organizations (PPO).
2. point of service
What is the focus of managed care?
Quality of care and lower cost outcomes.
These organizations were formed in 1972 to add an additional layer of review by professional standards organizations to impose an obligation on providers to support their provision of services.
professional standards review
Allows enrollees to use non-affiliated providers for an additional fee
Point-of-Service
Focuses on individual privacy rights.
HIPAA - Health Insurance Portability and Accountability Act
What is the exception to patient privacy? (i.e. child abuse, infectious disease, dangers to third parties, etc.)
Mandatory reporting laws
T/F Facilities generally own the records?
True
T/F Managed care has encouraged electronic health records
True
Accredits many types of healthcare entities including hospitals, healthcare networks, and PPOs. Has standards that govern the type of patient related data they collect.
Joint Commission on Accrediation of Healthcare Organizations (JCAHO)
Accredits managed care organizations and has elaborate specific medical records standards that apply to this type of organization.
National Committee for Quality Assurance (NCQA)
Joint Commission manual that addresses information management requiring PPOs to determine appropriate levels of security.
Accreditation Manual
Why has the managed care been a stimulus for computerization of health information?
Require a centralized database for medical records.
What is the statue that states the “record owner” refers to any healthcare practitioner who generates a medical records or who has records transferred from a prior practitioner?
Florida Statute 456.057 (a)
How did Maryland under the state Medical Records Act define “healthcare” provider.
This includes HMOs, agents, employees, officers and directors of healthcare facilities.
How is this different from the traditional definition?
More generic and less restrictive.
Difference between HMO and PPO?
HMO finances and arranges health care services.
PPO used by employer benefit plans and insurance carriers to contract with participating providers.
Compare and contrast PHO and MSO
PHO - Separate business entity. Contracts with hospital. Allows hospital and physicians to negotiate with third party providers.
MSO - Physicians remain independent contractors. Can be based around one or more hospitals.
Two associations that accredit managed care organizations.
Joint Commission on Accreditation of Healthcare Organizations (JCAHO) and National Committee for Quality Assurance (NCQA)
Basic principal of managed care.
Produce higher quality of care and lower cost outcomes.
What is the purpose of the HMO model?
To furnish most, if not all, of the covered services “in-house” through physicians employed by and facilities owned by the HMO.
Negotiates and manages rebates and price concessions from manufacturers or pharmacies.
pharmacy benefits managers (PBM)
