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.
