Explain How Managed Care Works Flashcards
What is managed care?
Type of healthcare system that manages utilization, quality, and cost of services.
Resources and services are closely monitored to ensure that the costs of services are within the amount that the insurance company will reimburse.
What are some examples of managed care?
HMOs and PPOs.
What is a managed care health plan?
A collection of interdependent systems that integrate the delivery of healthcare services to a specific population.
-Arrangements with selected providers to furnish a comprehensive set of healthcare services to members
-Credentialing standards for the selection of healthcare providers
-quality assurance and utilization review programs
-financial incentives for members to use providers and procedures associated with the health plan (network).
What is an HMO?
Health Maintenance Organization
Prepaid medical service plan that provides services to plan members.
Fixed payment per patient per month (Capitated payment)
Gatekeeper concept: PCP is go to
What are the advantages of an HMO?
No claim forms
Broader and more routine coverage
Predictable costs.
What are the disadvantages of an HMO?
Possibility of delayed payment for out-of-area services
Pre-approval for care needed
PCP directs patient care.
What are the HMO models?
Group model
Independent (or individual) practice association
Network model
Staff Model
What is the group model?
HMO contracts a multispeciality group for services.
What is the independent (or individual) practice association model?
HMO contracts an organized group of individual physicians.
What is the network model?
HMO contracts a combo of multispecialty groups, IPAs and independent physicians.
What is the staff model?
HMO employees physicians and healthcare workers.
What is a PPO?
Preferred Provider Organizations
Represents a network of hospitals and physicians who provide services to ensured plan members for a set fee.
What are the advantages of a PPO?
Ability to choose between doctors in the network
Choice to go to an out-of-network physician and receive some reimbursement but will be responsible for higher share of the cost.
What are the disadvantages of a PPO?
Higher premiums and out-of-pocket costs for PPO services than an HMO
In-network coverage is usually 80 to 100 percent with a co-payment for each office visit or hospital stay.
What are POS plans?
Insured chooses PCP but has option to receive care from hospitals or physicians that aren’t on the plan with a reduced level of benefits without referrals.
What are EPOs?
Exclusive Provider Organizations
Developed and implemented by employer groups that are trying to control costs.
Can only seek services from providers that are part of the EPO.
What are ACOs?
A group of healthcare providers who organize to provide care to Medicare patients.
What are Integrated delivery systems (IDSs)?
Healthcare networks that provide coordinated, organized and comprehensive care to a community’s population.
Hospitals, primary care physicians, and specialists link both preventative and treatment services through contractual and financial arrangemnets. Thus producing a network that provides coordinated care with continous monitoring of quality and accountability to the network enrollees.
One-stop shopping (All healthcare services through one place or one network.)
What are group practices without walls (GPWW)?
When physicians keep their own offices but share admin and management services with other managed care organizations.
What is IPO (integrated provider organization)?
An organization that manages and coordinates healthcare from several different providers and facilities.
What is MSO (Management service organization)?
A business that provides support services, like admin, to individual physicians.
What is a medical foundation?
Nonprofit organization that contracts with physicians to manage their practices.
What is a PHO (Physician-hospital Organization) also called medical staff-hospital organizations?
An organization that provides contract healthcare services between hospitals and doctors.
What is quality assurance (also known as quality management)?
Method that ensures the delivery of quality care in a healthcare facility.
What is the National Committee for Quality Assurance (NCQA)?
A private, nonprofit organization that is dedicated to improving the quality of healthcare.
Assesses and reports on the quality of managed care plans
What are the core set of values of the NCQA?
Improving healthcare
Providing accountability in healthcare
Empowering customers by providing information
Providing excellence in customer service.
What is accreditation when it comes from NCQA?
It means that a healthcare organization is evaluated and undergoes an examination of its policies, procedures, and performance by an external organization. (called accrediting bodies)
What is a voluntary accreditation?
Organizations aren’t required to receive it from NCQA but highly probably without it.
What is the Healthcare Effectiveness Data and Information Set (HEDIS)?
A set of standardized performance measures that consumers and employers use to compare the quality of managed-care plans.
How is information collected into the HEDIS database?
Random surveys through plan members
Claims and hospital data
Data tracked through various software systems
Data from patients’ health records (paper and electronic)
Information from credentialing boards (residency and physician boards)
Human resource data.
