Chapter 9

Question 1

Managed Care

Answer 1

around since 1990. single most dominant force in US healthcare unprecedented success from 27% to 95%

Question 2

What is managed Care

Answer 2

A mechanism providing health care services where a single organization takes on the management of 
financing
insurance
delivery
payment

Question 3

Accreditation and Quality Indicators

Answer 3

MCO’s are accredited by the National Committee for Quality Assurance NCQA. Accreditation is voluntary.

Question 4

HEDIS

Answer 4

Health Plan Employer Data and Information Set. Where the managed care report cards are contained. Includes many different measures on cost and quality.

Question 5

CMS Rating

Answer 5

Rated medicare part c on a 1-5 star scale using indicators such as quality of care, access, responsiveness, and beneficiary satisfaction.

Question 6

Evolution and Growth of managed Care

Answer 6

in early 1900 employers hired physicians to provide care.

1973-Health Maintenance Organization Act was passed to provide an alternative to fee for service by stimulating HMO’s

Question 7

First Private Health Insurance Plan

Answer 7

Baylor University Hospital in Dallas Tx 1929 prepaid plan.

Question 8

Most well known plan

Answer 8

Kaiser Permanente in California in 1942. Largest HMO in US.

Question 9

Gatekeeping

Answer 9

an arrangement that requires a Primary Care Physician to coordinate all health care services needed by an enrollee. emphasizes preventative care, routine physicals.

Question 10

Utilization Review

Answer 10

the process of evaluating the appropriateness of services provided. 3 types
Prospective
Concurrent
Retrospective

Question 11

Prospective Utilization Review

Answer 11

the medical necessity for certain tx is determined before care is delivered.

Question 12

Concurrent Utilization Review

Answer 12

appropriateness is determined during health care utilization

Question 13

retrospective utilization Review

Answer 13

managing utilization after services have been delivered

Question 14

HMOs

Answer 14

first type of managed care. Focuses of wellness care and capitation is the method of payment. Only in network, use of gatekeeping, specialty service upon referral, risk sharing with capitation providers
STAFF MODEL
GROUP MODEL
NETWORK MODEL
INDEPENDENT PRACTICE ASSOCIATION ipa MODEL

Question 15

PPO’s

Answer 15

Point of service plans, use both in and out of network, contracted providers only, no gatekeeping, restricted use of specialty, no risk sharing

Question 16

POS plans

Answer 16

use in and out of network, contracted providers only, unrestricted use of specialties, capitation and fee for service, some risk sharing.