Managed Care 2 Flashcards
Staff Model
HMO employs its own salaried physicians
Group Model
HMO contracts with a single multispecialty group practice and contracts separately with one or more hospitals to provide comprehensive services to its members.
Network Model
HMO contracts with more than one medical group practice.
IPA Model
Independent Practice Association model is a legal entity separate from the HMO which contracts with both independent solo practitioners and group practices.
PPOs
First appeared as competitive to HMOs. Offers open-panel options for enrollees and offers non capitation payment to providers.
Exclusive Provider Plan
If a PPO does not provide an out-of-network option
Point of service plans
Combine features of classic HMOs with some oof the characteristics of patient choice found in PPOs
Primary Care Case Management
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.
Risk Contracts
Medicare managed care contracts. The MCO is liable for services regardless of their extent, expense, or degree, in exchange for a fixed capitated fee.
Consolidation
A concentration of control by a few organizations over other organizations through a consolidation of existing facility assets.
Expansion
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.
Diversification
Addition of new services that the organization has not offered before
Integration
Refer to certain consolidations, expansions, or diversification that involve new products or services. Typically is a catch-all phrase.
Integrated Delivery System
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.
Accountable Care Organization
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
MSO
Management services organization. Provides management services to physician group practices.
PSO
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.
PHO
Legal entity that forms an alliance between a hospital and local physicians.
Acquisition
Purchase of one organization by another
Merger
Mutual agreement to unify two or more organizations into a single entity.
Joint venture
Two or more institutions share resources to create a new organization to pursue a common purpose.
Alliance
An agreement between two organizations to share their resources without joint ownership of assets
Virtual integration
The formation of networks based on contractual arrangements. Has no “walls.”
Horizontal Integration
Growth strategy in which a health care delivery organization extends its core product or service
Vertical Integration
Links services at different stages in the production process of health care
Antitrust
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.
