Chapter 27: Managed care Flashcards
Briefly describe theaim and list 5 objectivesofmanaged care
Aim:
Managed care is when the insurer intervenes in the provision of healthcare and aims tomanage claim costswhilemaintaining or even improving access to quality healthcare
Objectives:
1.reducing the costof healthcare
2.improving the qualityof healthcare
3.ensuring that medical servicesare delivered in an appropriate setting
4.ensuring that high-risk membersare managed and receive appropriate care
5.reducing the number of unnecessary medical services
List examplesofmanaged care programmes
methods aimed at policyholders:
limitations and exclusionson benefits
co-payments, levies and medical savings accounts
provider/ hospital networks
preventative medication/ screening tests
wellness programmes
formularies
hospital “take-home medication” management
requirement for a GP referral to be obtained before visiting a specialist
alternatives to hospitalisation
disease management programmes
methods aimed at healthcare providers:
treatment protocols
negotiated fees/ alternative reimbursement methods
utilisation management:
pre-authorisation of benefits
case management
Describe 5 risksinmanaged care
price risk:
the fee received by the provider does not cover variable costs or makes an inadequate contribution to overhead and profit
intensity risk:
more medical services are needed than expected
severity risk:
cases are more severe (refers to condition of patient) than expected
frequency risk:
more people need treatment than expected
profile risk
risk relates to the mix of lives covered
List4 disadvantageswithmanaged care
provider networks may restrict access to care
providers may resent external parties imposing restrictions on them and influencing the way in which they practice medicine
quality of care may be compromised by encouraging under-servicing by providers
use of formularies may result in the additional cost being transferred from the scheme to the member, with no overall cost reduction
Listmeasuresthat may be used toassess the quality of healthcare (under a managed care contract)
- patient mortaility rate, cause of death
- specialist referral rate
- hospital readmission rate
- procedure complication rate
- patient questionnaires
- treatment protocols for different types of admission
- hospital length of stay for different types of admission
- medical technology used
- staff numbers and skills (qualifications and experience)
- number of hospital beds
Describe the per diem structure in a hospital setting
hospitals are paid a set rate per day for all services provided, not dependent on actual level of care provided
structure can vary by type of admission (eg general admission, maternity)
per diem structure incentivises hospital to not over-service patient,
risk of under-servicing patient
main risks transferred are price and intensity risk
there is an incentive for hospitals to delay discharging patients
this can be managed by matching per diem payments more closely with hospital costs (eg higher amount for first day of surgical procedure)
Describe the fixed fee structure in a hospital setting
hospitals are paid a fixed fee per admission, regardless length of stay
structure can vary by type of admission (eg general admission, maternity)
fixed fee arrangement can be combined with per diem
eg per diems are used for more common treatments and fixed fees used for less common treatments
main risks transferred are price, intensity and severity risk
there is incentive for hospital to discharge patient and then re-admit patient
this can be managed by linking related admissions together
risk of under-servicing patient
Describe budget allocation as an alternative reimbursement method
provides operational budget to facility to cover all costs
more appropriate for state-owned facilities
Describe capitation as an alternative reimbursement method
calculated on a per prospective patient basis
may contract with network of facilities
main risks transferred are frequency and intensity risk
