managed care and OT Flashcards
Describe the characteristics of health maintenance organizations (HMO)
Closed panel of providers (may be co-located)
Gatekeepers (usually PCPs, to decide further treatment by specialists)
Provider reimbursement is capitated
Name 5 goals of managed care
- Best quality at lowest cost
- Durable and predictable outcome/standardized practice
- Coordinated and integrated care continuum
- Outcome effectiveness
- Prevention and health promotion focus
Describe the characteristics of Preferred Provider Organization (PPO)
Open or closed panel
Consumers pay discounted fee for in network providers (closed)
No or reduced reimbursement to consumers for providers out of network
May allow some consumer direction/choice
Describe point of service plans (POS)
- Contains both HMO and PPO elements
- Consumer reimbursed less if sees specialist versus primary care provider
Describe managed indemnity
- Uses fee for service approach
- Requires preauthorization and utilization review, especially for high cost procedures
- Not very common currently
What are the advantages of managed care for the consumer?
- Comprehensive, coordinated care
- Low out of pocket expenses
- Coverage for diagnostic procedures and hospitalization
- Minimal paperwork
- Emphasis on prevention and wellness
What are the disadvantages of managed care for the consumer?
- Restricted freedom of choice
- Difficulty getting referred to specialists
- Limited coverage for special needs( chronic conditions, non-medical ADL needs)
What are the advantages to managed care for OTs?
- Steady referral base and reliable cash flow
- Access to services within a large network(hospitals, rehab centers, individual practitioners)
- Opportunity to participate in interdisciplinary teams, outcome studies, EBP, clinical pathways, and clinical trials
What are the disadvantages of managed care for the OT?
- Decreased autonomy
- Restricted payments
- Financial risk (when client needs more than capitated amount)
- Conflicts between costs and quality
- Restrictions on referring to specialists
- Increased demands on documentation systems and data collection for outcomes
What are the implications of managed care for health care delivery systems?
- Shared resources: administrative, info systems, equipment and supplies, and legal counsil
- Shared risk: capitated payments encourage spreading of risk of high-cost patients across various organizations of systems
- Horizontal integration: Similar services at variety of locations (satellite sites)
- Vertical integration: Provision of all services across continuum of care, from emergency to long-term care
What are teh changes in practice sites due to managed care?
- Large, national consolidated rehab coporations
- Disappearance of independent practice opportunities
- Running health are practice as a business
Name at least 5 changes in OT practice due to managed care.
- Reduced reliance on OTRs for hands on care
- More opportunities for OTR in evaluation, consultation, program development, outcomes studies, and other research, and supervision
- Greater use of COTAs, tech and aides
- More co-treatment and group treatment
- More checklists, and computerized systems for documentation (streamlined, but less flexibility)
- Increased focus on functional progress
- Need for enhanced business skills, resource and fiscal management
- Need for increased assertiveness and advocacy skills on behalf of patients
- Need for generalist perspective (can fulfill many roles) as well as specialist skills
- Increased membership on interdisciplinary teams with program-specific structures
What are critical pathways?
- Care maps, practice guidelines
1. established protocol for health care
2. Goal is standardized and coordinated are
3. Associated with increased efficiency and predictable outcomes
4. Plots all services delivered against a time grid
5. Often mandated by MCOs (managed care organization)
What are the advantages to critical pathways?
- Increased communication, cooperation, and coordination between providers
- Increased professional opportunities
- Clear expectations and timetables and emphasis on patient/family teaching lead to high patient/family satisfaction
- Provides meaningful outcome data to payers
- Reduced lengths of stay in inpatient settings
What are some concerns with critical pathways?
- Takes time to develop (1-2 years)
- Too restrictive or prescriptive
What is the purpose of case/care management positions? What do they do? Who typically takes on these roles?
- Coordination of health care services to meet complex needs of clients, to integrate fragmented services, to control costs
- Involves skills of assessment, planning, implementation, coordination, monitoring and evaluation
- Typically practiced by nurses and social workers; recently OTs are getting certified
Where are case managers most often found?
Worker’s compensation programs
Community-based mental health
Post-hospital discharge of Medicare patients
Long-term care settings
What is the difference between cross-training and multiskilling?
Cross-Training: Learning skills of another profession while on the job
Multiskilling: Learning skills of another profession in advance like in school
why is cross-training appropriate?
OTs working with persons with complex needs may perform: ambulation training, orthopedic procedures, suctioning during feeding training, leading of family meetings and discharge meetings
OTs may see clients of all ages/diagnoses in rural or underserved areas
OT working in NICU or burn unit in acute care may see other hospital patients
Why are outcome evaluations required by MCOs?
- Identifies problem areas for investigation
- Provides research data
- Creates marketing info(grants, media, legislators)
- Provides internal info about resource management
- Contributes to future planning
What do outcome measures typically focus on?
Intervention results
customer satisfaction
How are OTs making the best of managed care changes?
- Opportunity for professional growth
- Using tx time to be more focused and accountable
- Shifting to teaching to caregivers, and other professionals, consultation, and supervision
- Finding opportunities to show/explain value of OT
PPS
Prospective Payment System
DRGs
Diagnostic Related Groups
