Managed Care 2

Question 1

Staff Model

Answer 1

HMO employs its own salaried physicians

Question 2

Group Model

Answer 2

HMO contracts with a single multispecialty group practice and contracts separately with one or more hospitals to provide comprehensive services to its members.

Question 3

Network Model

Answer 3

HMO contracts with more than one medical group practice.

Question 4

IPA Model

Answer 4

Independent Practice Association model is a legal entity separate from the HMO which contracts with both independent solo practitioners and group practices.

Question 5

PPOs

Answer 5

First appeared as competitive to HMOs. Offers open-panel options for enrollees and offers non capitation payment to providers.

Question 6

Exclusive Provider Plan

Answer 6

If a PPO does not provide an out-of-network option

Question 7

Point of service plans

Answer 7

Combine features of classic HMOs with some oof the characteristics of patient choice found in PPOs

Question 8

Primary Care Case Management

Answer 8

A model that requires a Medicaid enrollee to choose a PCP, who is responsible for coordinating the enrollee’s care and paid a monthly fee for doing so, on top of payment for providing medical services.

Question 9

Risk Contracts

Answer 9

Medicare managed care contracts. The MCO is liable for services regardless of their extent, expense, or degree, in exchange for a fixed capitated fee.

Question 10

Consolidation

Answer 10

A concentration of control by a few organizations over other organizations through a consolidation of existing facility assets.

Question 11

Expansion

Answer 11

Growth strategy in which an organization adds services new or similar to exitsting ones. Expansion is different from consolidation because it involves building NEW facilities and not just including exit sting ones.

Question 12

Diversification

Answer 12

Addition of new services that the organization has not offered before

Question 13

Integration

Answer 13

Refer to certain consolidations, expansions, or diversification that involve new products or services. Typically is a catch-all phrase.

Question 14

Integrated Delivery System

Answer 14

A network of organizations that provides or arranges to provide a coordinated continuum of services to a defined population and is willing to be help clinically and fiscally accountable for the outcomes and health status of the population serviced.

Question 15

Accountable Care Organization

Answer 15

An integrated group of providers who are willing and able to take responsibility for improving the overall health status, care efficiency, and satisfaction with care for a defined population

Question 16

MSO

Answer 16

Management services organization. Provides management services to physician group practices.

Question 17

PSO

Answer 17

Provider sponsored organization. Sponsored by physicians, hospitals, to compete with regular MCOs by agreeing to provide health care to defined group of enrollees under capitation.

Question 18

PHO

Answer 18

Legal entity that forms an alliance between a hospital and local physicians.

Question 19

Acquisition

Answer 19

Purchase of one organization by another

Question 20

Merger

Answer 20

Mutual agreement to unify two or more organizations into a single entity.

Question 21

Joint venture

Answer 21

Two or more institutions share resources to create a new organization to pursue a common purpose.

Question 22

Alliance

Answer 22

An agreement between two organizations to share their resources without joint ownership of assets

Question 23

Virtual integration

Answer 23

The formation of networks based on contractual arrangements. Has no “walls.”

Question 24

Horizontal Integration

Answer 24

Growth strategy in which a health care delivery organization extends its core product or service

Question 25

Vertical Integration

Answer 25

Links services at different stages in the production process of health care

Question 26

Antitrust

Answer 26

Policy consists of federal and state laws that make certain types of business transactions illegal. Such as price fixing, price discrimination, exclusive contracts, and mergers among competitors.