Healthcare and Managed Care Flashcards
What are the requirements of a well-functioning healthcare system?
- Must be well funded.
- Must have well-training medical professionals.
- Knowledge must be freely shared.
- Must have good facilities, e.g., hospitals, clinics, etc.
Who are the funders of healthcare?
- Government organizations: usually fund the bulk of healthcare. <
- Non-government organizations.
- Individuals: those with insurance through co-payments; those without insurance through healthcare; those receiving medical services not invoiced.
- Employers: fund part or all of insurance for employees.
- Insurers.
- Trade-related employer groups - bargaining councils form a scheme to benefit members. Usually provides basic primary healthcare to members and managed care options.
What are the supply-side key providers?
- Hospitals.
- Healthcare specialists.
- Upstream providers, e.g., pharmaceutical industry.
What are the different managed care services?
Story: Clint Eastwood from Gorrilaz, goes to Herschel to try and get high. He needs a sticker, to be authorised to go in. Otherwise, he has to write the proof to a formula, this is the protocol. When he comes in Malcom Gladwell is with him, with discharge on his shoes. He solves the proof then gets let in where it’s just all the bursery students trying to adjust the risk of their skirts being too long or else they are sent to one of the selected providers with a scissors to cut the skirt.
- Clinical audits.
- Education and support.
- High-cost case management.
- Pre-authorization management.
- Formularies and protocols.
- Outlier management.
- Discharge planning and alternatives to hospitalization.
- Reimbursement methods.
- Risk adjustment.
- Provider and Hospital network.
What is the main objective of managed care?
- To decrease the number of unnecessary medical services.
- To manage the costs of healthcare services to ensure they are affordable.
- To ensure that treatment is carried out at the appropriate facility.
- To ensure that good quality healthcare services are provided.
- Ensure that high-risk patients are managed and receive appropriate care.
What are the different reimbursement methods for providers?
- Fee-for-service.
- Modified (negotiated) fee-for-service.
- Capitation.
- Salary.
- Per-diem.
- Per-case.
- Episode of care.
- Pay for coordination.
- Pay for performance.
- Pay for participation.
What are the risks of managed care?
- Super high-risk individuals might be excluded from receiving healthcare.
- Drug formularies might not reduce costs but instead transfer costs from insurer to patients.
- Doctors might be upset that managed care dictates their practice.
- Hospitals might be encouraged to under-service patients through reimbursement methods.
What are some of the risks transferred from funder to provider?
- Frequency risk: more cases than expected.
- Actuarial risk: demographics are worse than expected, price is inadequate;
- Marketing risk: fewer individuals take up healthcare cover, affecting demographics and actuarial risk.
- Intensity risk: more services needed per patient encounter.
- Severity risk: more expensive or complicated services required.
What benchmarks can be used in order to assess the quality of care?
- Infant mortality rate.
- Specialist referral rate.
- Hospital re-admission rate.
- Procedure complication rate.
- Chronic medication adherence.
- Patient questionnaires.
It is important that these benchmarks are standardized for age, gender, and ethnicity to be comparable.
How might managed care intervention be applied to group products?
- Tailor managed care interventions for each group’s requirements.
- Use hospital networks in area where employer operates.
- Use a network of specialists in area where employer operates, target specialist in fiel which employees most at risk of needing treatment from.
- Employ a health professional at the place of business.
- Could also be put into practice for employers themselves.
- Protocols: minimum standards of health and safety; encourage healthy lifestyles.
Fee for service
- Healthcare providers paid for each healthcare service provided.
- The fee paid is standardized across the industry.
- The fee is set by healthcare provider representative bodies.
- PH can go to any provider that they choose.
- Incentivizes volume, not value, leading to increased healthcare costs.
- Rewards productivity, does not promote accountability.
Modified (negotiated) fee-for-service
- Healthcare providers paid for each healthcare service provided. - Maximum fee negotiated for every service.
- The fee is negotiated by insurer/HMO.
- PH may be limited to seeking treatment from a network of preferred providers.
Capitation
- Providers receive a fixed, pre-determined amount per enrolled member, usually monthly, regardless of actual services provided or their costs.
- Payment is risk-adjusted for disease burden.
- Providers exposed to both utilization and cost risks.
- Patients and funders risk under-servicing and reduced quality of care.
Salary
- Healthcare professionals can be employed by the insurer or the HMO to provide services to the PH base.
Per-diem
- Hospitals are paid a fixed amount per day the policyholder is hospitalized, regardless of the reason for care.
- Encourages provider to keep patient hospitalized for longer than necessary, solved by discharge planning
