managed health care Flashcards
What are the advantages of indemnity health insurance?
Unlimited provider access
Unlimited choice
What is an indemnity?
Traditional form of health care in which providers are paid for services rendered, also know as FFS. Fee for service.
What are the disadvantages of indemnity healthcare?
Higher out of pocket cost, ie deductible nod coinsurance.
Fewer benefits, such as wellness programs
No coordination of care
May not cover preventative care.
What is managed care?
A system of health care that combines delivery and payment while managing utilization of services to promote cost effective healthcare.
What are the advantages of managed healthcare?
Preventative focus
Lower out of pocket costs
Higher coordination of care via a gate keeper
Disease management and quality improvement focus.
What are the disadvantages of managed health care?
Limited choice of providers
Limited access to specialists
What is an HMO?
Health maintenance organization.
Generally provides access to full healthcare services including preventative care with the restriction that members must use network providers.
What is a PPO.
Preferred provider organization.
An arrangement between purchasers of care and network providers to offer services at a reasonable cost use incentives to stay in network. ie lowered deductibles and co payments
What is an EPO?
Exclusive provider organization.
The network is made up or providers from which the member must choose(exceptions for emergency) primary care doc will handle most medical issues and will refer to specialist. EPO carriers are able to negotiate lower rates for members because they are restricted to in network only.
What is capitation?
A method of payment for health services in which the provider is payed a fixed amount for each patient without regard to the nature of service.
What is an IPA?
Independent practice association model.
Where an HMO contracts with independent private practice physicians or associations of such physicians who then provide care for members as well as patients.
Physicians are usually paid on a modified FFS
What is a group model?
a physician group, usually a large number of physicians and specialist that contract with an HMO to provide services for a fixed advanced payment. (Kaiser)
What is a POS?
Point of service coverage. an open ended HMO that encourages, but does not require a member to choose a Primary care to act as a gatekeeper when making referrals. Members also have the choice of paying higher deductible and copayments for non- network providers. ( Cigna Open access POS organization)
What is a staff model?
an HMO in which Physicians provide care exclusively for the health plan. The Physicians are employees of the health plan.
What is a managed indemnity?
A managed care plan that is administered similarly to traditional indemnity plans but incorporates managed care features, such as pre admission certification or utilization reviews.
What is a CDHP?
consumer driven health plan.
a health care plan where the beneficiaries are more directly responsible for their own healthcare decisions and cost allotment.
What are the advantages of a CDHP plan?
Premiums are usually lower.
premium cost savings are shared by employers and employees
HSA’s enable ownership of healthcare spending and promote greater responsibility.
Programs promote patient choice and control over medical care, which may help control costs.
What are the disadvantages of an CDHP?
The risks are shifted to the consumer, potentially burdening patients with high out of pocket costs.
lack of adequate information resources to help make cost effective and appropriate decisions.
needed benefit may not be covered.
What is a DUE?
Drug Utilization evaluation.
a system by which drug use is reviewed to detect safety issues such as a potential adverse drug interaction, pregnancy conflicts, therapeutic duplication and drug age conflicts.
What are some examples of Utilization Management?
Formulary
PA
Referral
Step Therapy
in 2011 what percentage of healthcare expenses where paid for by the government?
28%
What is medicare?
a federally funded health insurance program for people aged 65 and older, as well as disabled americans, people of any age with end-stage renal disease and patients with severe mental illness.
What does Medicare part A cover?
inpatient hospital services, skilled nursing facility care, hospice, inpatient psychiatric care and home health care.
What does Medicare Part B cover?
Physicians fees, out patient and home health care, durable medical equipment and some preventative services(mental health).
What does medicare Part C cover?
Medicare advantage plus plans..health care options approved by medicare and run by private companies.
What does Medicare Part D cover?
approved prescription drugs.
What is Medicaid?
a type of medical assistance funded by the states and the federal government. For Low income, elderly, blind, disabled, or with families that have dependent children.
What is covered under Tier 1 formulary?
Generic products
What is covered under tier 2 formulary?
proffered brand products
What is covered under tier 3 formulary?
non- preferred or covered brand products
What is covered under tier 4 formulary?
Specialty drugs often very high cost and name brand such as biologics.
What is the goal of tiered formularies?
to preserve the choice for patients and physicians
provide some level of coverage for most drugs
encourage prescribing of drugs deemed more cost effective for the plan.
What is NCQA
national committe for quality assurance.
helped develop measures and standards that organizations and individuals can use to evaluate the quality of healthcare.
developed HEDIS, health plan employer data and information to measure in the form of stats, the quality of care delivered by heath plans.
What is AHRQ?
Agency for Healthcare research and quality. part of the us department of health and human services on quality research. they measure health care quality through inpatient administrative data.
What is the joint commission?
they develop standards and evaluate the quality and safety of healthcare delivery.
What is the URAC?
Utilization review accreditation Commission.
accredits many types of healthcare organizations, including hospitals, MCO’s and provider groups.
