Health Maintenance Organisations - HMPD Flashcards
What is managed care?
Managed care is a system aimed at reducing the cost of healthcare while improving the quality of care by using a network of providers accountable for cost containment and health outcomes.
What are the goals of managed care?
Ensure high-quality care while controlling costs, deliver relevant healthcare services based on patient needs, and ensure care is rendered by the most appropriate provider in the right setting.
What are the key principles governing the delivery of managed care?
Selective provider contracting, utilization management, negotiated payment, and quality management.
What are Managed Care Organizations (MCOs)?
Organizations that use managed care techniques or provide them as services, functioning as systems for delivering health insurance to the populace.
What is a Health Maintenance Organization (HMO)?
A type of managed care organization that offers prepaid health care coverage through a network of providers.
What are the characteristics of an HMO?
Contracts with providers for services at a fixed rate, charges a fixed monthly fee, and sometimes includes small co-payments for each visit.
What is capitation in the context of HMOs?
A system where providers receive a fixed payment per member per month and offer services without additional payment for extra care, potentially limiting unnecessary services.
What is the role of the Primary Care Physician (PCP) in an HMO?
The PCP acts as a gatekeeper, managing access to specialist care and referrals within the HMO system.
What are the costs associated with an HMO?
Monthly premiums, co-payments, and deductibles are common costs associated with HMO coverage.
What cost-control mechanisms are used by HMOs?
Primary care physicians to track costs, use of physician assistants, exclusion of unnecessary services, emphasis on prevention, and limited provider choice.
How is payment made in an HMO system?
Per-capita payments are made to healthcare providers, while per-case, diagnostic related groupings, and global budgeting may be used at secondary and tertiary levels.
What are the payment methods used by HMOs for secondary and tertiary care?
Per-case payments, diagnostic related groupings, and global budgeting.
What is the function of HMOs in Nigeria?
To manage healthcare provision, collect contributions, pay providers, ensure quality assurance, and market according to NHIS guidelines.
What are the core functions of HMOs in Nigeria?
Collecting contributions, contracting with healthcare providers, ensuring quality assurance, and rendering returns to the National Health Insurance Scheme (NHIS).
What is the role of the Primary Health Care Provider (PHCP) in HMOs?
The PHCP is the first point of contact for contributors and can refer them to hospitals or specialists when necessary.
