Test 3 Basic Concepts of Group Insurance Flashcards
Discuss the primary precept group health insurance.
- individuals pay a fixed amount of money
- pooled money pay for a defined set of healthcare services
What are the objectives that managed care was developed to address?
- Increasing access for members
- Improving quality and outcomes
- Controlling costs
What problems was managed care developed to resolve?
- Rising healthcare costs
- Fragmented healthcare delivery
What are the differentiating characteristics of MCO plans?
- risk bearing
- physician type
- relationship exclusivity
- out-of-network coverage
risk bearing
- assuming the responsibility of the healthcare cost of the patient
- consists of: capitation, risk pools, gatekeeper
physician type
- staff physician
- contracted as a group
- contracted as an individual
relationship exclusivity
limits how much patients can see outside of managed care organizations; ex. you can only see BCBS pts
out-of-network coverage
insurance company contract with a company with the best rates; you get the best rates if you go there; if you go outside of that, it’s going to cost you more
Types of HMOs
- staff model
- group model
- network model
- independent practice association
Consumer-Directed Health Plans (CDHPs)
main goal is to introduce consumer’s to the financial implications of their
Pharmacy Benefit Manager (PBM)
focuses on managing pharmaceuticals
tenets of managed care
- managed care is a subscription
- prefunded delivery system with defined contributions and covered benefits
- participants are financially linked and share risks due to contract agreed upon
- costs controlled by controlling supply and demand
strategy to manage financial risk
- financial risk-sharing
- influence behavior of all stakeholders
- promote cost-effective decision making
HOW does managed care organizations manage financial risk?
– Discounted reimbursement rates
– Incentives for achieving performance standards
– Copayment structures
– Drug company discounts and rebates
– Underwriting
– Contracting and reimbursement mechanisms
