Textbook Chapter 17 - Managed Healthcare Flashcards
MCOs assume ________ for expenditures and have incentives to control ____ and _____ of healthcare services
Assume FINANCIAL RISK and have incentives to control COSTS and UTILIZATION of healthcare
MCOs assume ________ for expenditures and have incentives to control ____ and _____ of healthcare services
Assume FINANCIAL RISK and have incentives to control COSTS and UTILIZATION of healthcare
Who was Kaiser
Started a medical delivery system for his 15,000 workers building a dam
Workers were covered for work injuries only, BUT additional coverage for themselves and dependents could be purchased for 50c and and 25c a week for child
What did the Health Maintenance Organization Act require
Required employers with greater than 25 employees that offered a health plan to also offer an HMO type of alternative to an indemnity plan
What did the Health Maintenance Organization Act require
Required employers with greater than 25 employees that offered a health plan to also offer an HMO type of alternative to an indemnity plan
What is the DIFFERENTIATING FEATURE between FFS plans and managed care
The use of provider networks
What are the 4 characteristics that differentiate the types of MCOs
- Risk bearing
- Physician type
- Relationship exclusivity
- Out of network coverage
explain what risk bearing means in relation to MCOs
The amt of risk borne by the provider (ranges from full risk to no risk)
Explain “relationship exclusivity” as it relates to MCOs
Whether the physician provides care to patients from 1 MCO or multiple MCOs
Give the characteristics of HMOS in regards to out of network coverage and risk bearing
NO COVERAGE OUT OF NETWROK
-they place providers at risk (capitation, risk pools, gate keepin)
Name and explain the 3 HMO provider risks
Capitation —- providers are paid a SET COST for a specified period of time. They’re obligated to provide all needed care for that population in the time period
Risk pools — portion of physician payment is “withheld” to cover any claims that exceed the expected projections. HMO and provider share in surplus loss at end of year
Gatekeeper — a PCP must coordinate and authorize all medical services in order to be covered. They are financially at risk in order to minimize unnecessary services
Name the 4 types of HMOs
Staff model
Group model
Network model
IPA model (independent practice association)
What is happening in a staff model HMO
The HMO directly owns the facilities and the providers are the employees. The physicians bear NO RISK but are subject to utilization review
What is happening in a group model HMO
HMO contracts with large, multi speciality medical groups. They can only offer services exclusively to the HMO
CAPITATED
What is happening in a network model HMO
NONEXCLUSIVE contracts with large medical groups
Physicians bear risk
What is happening in an IPA HMO model
Physicians for a separate legal entity and then contracts with the MCO — IPA and MCO share risk
Usually have their own practices and can provide patients in other MCOs and individual patients
What are PPOS
Type of MCO.
Affiliations of providers that seek contracts with insurance plans
Explain PPO
NON EXCLUSIVE
Free to see any provider but there are financial incentives to see in network
Provides bear no risk but re subject to utilization management
____ are a form of PPO that strictly limits participation among providers
EPOS
Explain hybrid plans
Combine 2 or more organizational models
Ex — point of service plan
Patient chooses provider at the TIME OF SERVICE rather than upon joining the plan
Diff coverage for in and out of network
Becoming more prevalent
Are PBMS considered MCOs?
NO — but they have many characteristics of managed care (including a network)
PBMS contract with a network of ___
Pharmacies
What do PBMS use to compare network pharmacies
Report cards
Who offers rebates to PBM? In exchange for what?
Manufactures offer rebates in exchange for placement on a formulary
