Managed Care Flashcards
What are the 3 managed care principles?
⭐️Limited access to providers
⭐️Payment rewards efficiency
⭐️Quality improvements
Within managed care this principle is is applied by open/closed gate panels and is decribed as a controlled number of providers…
Limited access to providers
Within managed care this principle is is applied by Credentialing,Gatekeeping,Discounted fee-for-service,Case based payment, and Per member per month. It’s decribed by Controlled patient access,Discounted fee-for-service, Bundling, and Capitations…
Payment rewards “EFFICIENCY”
Within managed care this principle is is applied by Utilization review, Clinical pathways, Benchmarking, and Case management. Its decribed by Data collection and Peer review…
Quality Improvement (enhanced quality control procedures)
What are the types of managed care products?
⭐️Managed Indemnity Insurance
⭐️Preferred Provider Organization (PPO)
⭐️Health Maintenance Organization (HMO)
⭐️Point Of Service (POS)
Which managed care product carries the characteristics of
- Open Panel
- Discounted fee-for-service
- Preauthorization &
- Utilization Review
Managed Indemnity (MI)
Which managed care product carries the characteristics of
- Open or Closed Panel
- Discounted fee-for-service and case based payment &
- Preauthorization/Utilization Review
Preferred Provider Organization (PPO)
Which managed care product carries the characteristics of
-Closed Panel
-Discounted fee-for-service, case-based payment, or capitation &
-Gatekeeper Authorization
(Big rise in the 80’s)
Health Maintenance Organization (HMO)
Which managed care product carries the characteristics of
- Contains both HMO & PPO plans
- Better reimbursment for HMO
- Can choose the provider based on service needed
Point Of Service (POS)
What is managed care?
A system that intergrates the financing and delivery of health services.
Within managed care market shares which product is most common and which is becoming less common?
- PPO is most common
- Managed Indemnity is the least common
What are the concerns of managed care in PT/OT?
- Less visits
- Less reimburstement
- Less autonomy
What are the benefits of MCO’s?
- Use of Evidence Based Management (EBM); fact based
- Patients must take more responsibility
- Emphasis on preventative care
In 1973, the American Hospital Association’s House of Delegates adopted this due to ethical concerns about physicians recieving financial incentives to avoid referring patients to specialists.
Supposed to guarantee patients information, fair treatment, and autonomy over medical decisions.
Patient Bill Of Rights (state enforced)
The key professionals in the managed care environment that coordinate all aspects of patients care and access are (not always a healthcare provider)(usually nurses)(can be PT/OT)…
Case Managers
