Managed Care Lecture part 1 Flashcards
What is managed care?
An organized approach to deliver comprehensive svcs to a grp of enrolled members through efficient management of svcs and negotiation of prices with providers.=
What are the 2 core features of managed care?
Integration of the 4 functions of a HC system
Formal control over utilization
Role of managed care in financing
Negotiation of premiums with employers
Role of managed care in insurance
The MCO assumes insurance risk
Role of managed care in delivery
MCO’s own physicians and hospitals or contracts with providers
Role of managed care in payment
Using 3 methods (capitation, discounted fees, salary) for risk sharing between the MCO and providers
What were the main factors in managed care’s growth?
Flaws in fee for service
Employers’ response to rise in premiums
Weakened economic position of providers
How did flaws in fee for service contribute to managed care’s growth?
Uncontrolled utilization d/t moral hazard and provider-induced demand
Uncontrolled prices and payment d/t itemized billing of charges by the provider to the insurer
-Insurers functioned simply as passive payers of claims
-Focus on illness rather than wellness: sickness coverage; no coverage for wellness and prevention; no control over costly hospitalizations
Trends in employer’s response to rise in premiums
Annual increase in private insurance costs by over 12% between 1980-1990
Employer based insurance with managed care: 27% in 1988, 95% in 2003
How did weakened economic position of providers contribute to managed care’s growth?
Excess capacity in hospitals brought on by the Medicare prospective payment system led to weakened bargaining power of hospitals
Physicians gave in to the momentum of managed care leading to participation or being left out
Efficiencies in managed care
Eliminating insurance and payer intermediaries
Cost control through risk sharing with providers or extracting discounts from providers
Cost savings by coordinating pt svcs and monitoring the delivery of svcs for appropriateness
Gatekeeping to reduce moral hazard
Saving money through illness prevention and early detection and tx
Inefficiencies in managed care
Complexity for providers of having to deal with numerous plans
Carved out laboratory and other services are creating inconveniences for pts and providers
Lengthy appeals for denied svcs
What are the cost control methods of MCOs?
Choice restriction
Gatekeeping
Case management
Dz management
Pharmaceutical management
Utilization review
Practice profiling
Choice restriction in MCOs
Closed panel
Open access
Definition of closed panel
In-network access
No access outside the panel
Definition of open access
Out-of-network access
Outside option is allowed, but at a higher out-of-pocket cost
Gatekeeping and MCOs
PCP as portal of entry
PCP delivers basic and routine care
PCP refers and coordinates when secondary care is needed
Gatekeeping achieves modest cost savings
Case management and MCOs
Coordination of care for complex and potentially costly cases
A variety of svcs from multiple providers over an extended period
Coordination of an individual’s total HC in consultation with primary and secondary care providers by an experienced HC professional, such as an NP
What does utilization management require?
An expert evaluation of what svcs are needed
A determination of how to provide svcs inexpensively without compromising quality
A review of the process of care and changes in the pt’s condition
Dz management and MCOs
Pop-oriented strategy for chronic problems
Evidence-based tx guidelines
Focus on education, self-management training, monitoring of the dz process, and f/u to ensure compliance
To prevent or delay complications
Although cost savings are uncertain, better quality and dz control or achieved
What are the 3 main strategies of pharmaceutical management in MCOs?
Drug formularies
Tiered cost sharing
Pharmacy benefits management companies (PBMs)
Responsibilities of pharmacy benefits management companies
Extract discounts form pharmaceutical manufacturers
Handle drug utilization review
What does utilization review ensure?
Appropriate levels of svcs are delivered
Care is cost-efficient
Subsequent care is planned
What are the three main types of utilization review by the time when the review is undertaken?
Prospective UR
Concurrent UR and d/c planning
Retrospective UR
Aspects of practice profiling
Evaluate provider-specific practice patterns
Profile monitoring
Compare to a norm
Feedback to change behavior
Goal: improve quality and efficiency
Somewhat controversial
