Lecture 8 done Flashcards
What is managed healthcare?
movement away from strick paymentfor services to controlling the provision of healthcare services
What is an MCO?
managed care organizations who assume financial risk for expenditures
What are the features of managed care?
1)prepaid health coverage(prospective payment) 2)provider networks, 3)cost and utilization controls
True or false: all healthcare organizations and insures use MCO’s to some extent today.
true
Describe the characteristics of health maintenance organizations(HMOs)
providers share financial risk, Gatekeepers(PCP must authorize medical services), do not cover out of network
Describe preferred provider organizations(PPOs).
affiliations of providers that contract with insures, discounted fee-for-service payment instead of capitation
What is an exclusive provider organization(EPO).
PPO that doesn’t cover out of network providers
What is a challenge of managed care?
balance patient needs with allocation of healthcare resources
Who preforms hospital accreditation?
joint commission, voluntary complience with standards
WHo does Pharmacy accreditation?
joint commission, center for pharmacy practice accreditation, URAC
WHat is prospective payments?
used in hospital/clinic setting
What is retrospective payment?
outpatient, fee-for-service
WHat is the role of pharmacy benefit managers?
complexity of drug benefits, performance quarantees
What services are provided bu PBMs?
pharmacy network development, claims processing, formulary management, rebate contracting, drug utilization review, adhearence programs, audits, disease managements specialty drug programs
