Managed care lecture, part 2 Flashcards
What are the 3 main types of MCOs?
Health maintenance org (HMO)
Preferred provider org (PPO)
Point-of-service (POS), hybrid of HMO and PPO
Aspects of HMOs
Both medical care for illness and preventive care
PCP as gatekeeper
Capitation
In-network access (except hybrid and triple-option plans)
Carve outs for special svcs
Required to comply with standards of quality
Aspects of PPOs
Contracts with a grp of physicians and hospitals
Open-panel option
Discounted fee arrangement with providers (no direct risk sharing)
Fewer restrictions to the care seeking behaviors: no gatekeeping and other controls
Aspects of POS
HMO features: gatekeeping utilization controls, capitation
PPO feature: open access option available at the point of svc
Later, the need for POS plans became less important
What are the models of HMOs?
Staff
Group
Network
Independent practice association (IPA)
Staff model
Employ physicians on salary
Contracts for only uncommon specialties and hospital svcs
Greater control over practice patterns of physicians
Least popular model
Group model
Contract with a single multispecialty grp practice
Separate hospital contracts
Grp practice is paid a capitation fee
Network model
Contract with more than one grp practice
A wider choice of physicians
Diluted utilization control
Independent practice association model
An intermediary representing physicians
HMO contracts with IPA
IPA (not HMO) contracts with providers
Less leverage in changing physician behavior
D/t a surplus of specialists in many IPAs, there is some pressure to use their svcs
Advantages of staff model
Greater control of practice patterns of physicians
Convenience of one-stop shopping
Disadvantages of staff model
Fixed salary expense can be high
Expansion into new markets is difficult
Limited choice of physicians
Advantages of group model
No salary or facility expenses
Well known practice may lend prestige
Disadvantages of grp model
Difficulty with svc obligations if a contract is lost
Advantage of network model
Wider choice of physicians
Disadvantage of network model
Dilution of utilization control
Advantages of IPA model
Eliminates the need to contract with various providers
Transfers financial risk to the IPA
Choice of providers
Disadvantages of IPA model
Difficulty with svc obligations if a contract is lost
Less leverage in changing physician behavior
Dilution of utilization control
A surplus of specialists
Trends in employment based health insurance enrollment with managed care
Plans with dollar-level employer contribution lead to workers paying more if they choose a more expensive plan
Enrollment of workers in PPO: 61% in 2005, 57% in 2013
Health insurance exchanges
-Managed care plans to be dominant payers in the exchanges under the ACA
-Must comply with ACA mandates
Medicaid enrollment trends with managed care
Enrollment of Medicaid beneficiaries in HMOs increased to 85% in 2015
Primary care case management (PCCM) model used in many states
Requires enrollee to choose PCP
PCP coordinates enrollee’s care and is paid a monthly fee for doing so
Medicare enrollment trends in managed care
Level of participation in Medicare part C depends on the amt of reimbursement
In 2015, 32% of Medicare beneficiaries in managed care
Payments to Medicare Advantage plans will be reduced under the ACA
What percentage of workers were enrolled in PPOs in 2016?
48%
Managed care’s impact on cost?
Better value than indemnity insurance
Backlash from consumers and providers led to weaker cost control efforts
Full potential was not realized
Managed care’s effect on access
Good access to primary care and preventive svcs in certain key areas
On a larger scale, impact on access is not well established
Managed care’s effect on quality
Overall, quality of care in MCO plans = traditional FFS
No evidence of skimping on care bc of capitation
Lower quality in for-profit plans vs non-profit plans
Enrollees of Medicare Advantage have a higher likelihood of rehopsitalization compared to those in original Medicare
Backlash, regulation, and aftermath on quality in managed care
Backlash from consumers, physicians and legislators led to regulations against managed care
Relaxed utilization controls
More bargaining power to providers
Organizational integration
