Study guide for the final, part 9 Flashcards
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
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 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
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
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
Network model
Contract with more than one grp practice
A wider choice of physicians
Diluted utilization control
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
Horizontal integration
Extends core product or svc
To control the geographic distribution of a certain type of HC svc
Not for diversification
Vertical integration
Links svcs at different stages in the production process of HC (across a continuum of care)
A diversification strategy
What are preferred by most older people and more rapidly grown than institutional svcs?
Community-based svcs
Financing in LTC
Generally not covered by regular health insurance
Private LTC insurance has made limited headway
2/3 of total LTC spending paid by Medicaid
Nature of LTC
Variety of svcs
Individualized svcs
Well-coordinated total care
Maintenance is residual function
Extended period of care
Holistic care
Quality of life
Use of current tech
Use of evidence-based practices
What are the LTC svcs?
Medical care, nursing, and rehab
Mental health svcs and dementia care
Social support
Preventive and therapeutic LTC
Informal and formal care
Respite care
Community based and institutional svcs
Housing
End of life care
Who is the single largest payer for home health care svcs? Who is the 2nd largest payer?
Medicare
Medicaid
Three cornerstones of HC delivery
Cost
Access
Quality
High quality care = ?
The most cost-effective care
Cost is important in evaluating quality
Reasons to control HC costs
Currently consuming greater portions of the total economic output
Resources should be directed to their highest valued uses
Corporations bear the additional cost of doing business
A toll on avg and low-income Americans
Public spending for HC will become unstable
Reasons for cost escalation
Third party payment
Imperfect market
Growth of technology
Increase in elderly pop
Medical model of health care delivery
Multipayer system and admin costs
Defensive medicine
Fraud and system abuse
Practice variations = small area variations (SAV)
