Textbook Chapter 17 - Managed Healthcare

Question 1

MCOs assume ________ for expenditures and have incentives to control ____ and _____ of healthcare services

Answer 1

Assume FINANCIAL RISK and have incentives to control COSTS and UTILIZATION of healthcare

Question 2

MCOs assume ________ for expenditures and have incentives to control ____ and _____ of healthcare services

Answer 2

Assume FINANCIAL RISK and have incentives to control COSTS and UTILIZATION of healthcare

Question 3

Who was Kaiser

Answer 3

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

Question 4

What did the Health Maintenance Organization Act require

Answer 4

Required employers with greater than 25 employees that offered a health plan to also offer an HMO type of alternative to an indemnity plan

Question 5

What did the Health Maintenance Organization Act require

Answer 5

Required employers with greater than 25 employees that offered a health plan to also offer an HMO type of alternative to an indemnity plan

Question 6

What is the DIFFERENTIATING FEATURE between FFS plans and managed care

Answer 6

The use of provider networks

Question 7

What are the 4 characteristics that differentiate the types of MCOs

Answer 7

1. Risk bearing
2. Physician type
3. Relationship exclusivity
4. Out of network coverage

Question 8

explain what risk bearing means in relation to MCOs

Answer 8

The amt of risk borne by the provider (ranges from full risk to no risk)

Question 9

Explain “relationship exclusivity” as it relates to MCOs

Answer 9

Whether the physician provides care to patients from 1 MCO or multiple MCOs

Question 10

Give the characteristics of HMOS in regards to out of network coverage and risk bearing

Answer 10

NO COVERAGE OUT OF NETWROK

-they place providers at risk (capitation, risk pools, gate keepin)

Question 11

Name and explain the 3 HMO provider risks

Answer 11

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

Question 12

Name the 4 types of HMOs

Answer 12

Staff model
Group model
Network model
IPA model (independent practice association)

Question 13

What is happening in a staff model HMO

Answer 13

The HMO directly owns the facilities and the providers are the employees. The physicians bear NO RISK but are subject to utilization review

Question 14

What is happening in a group model HMO

Answer 14

HMO contracts with large, multi speciality medical groups. They can only offer services exclusively to the HMO

CAPITATED

Question 15

What is happening in a network model HMO

Answer 15

NONEXCLUSIVE contracts with large medical groups
Physicians bear risk

Question 16

What is happening in an IPA HMO model

Answer 16

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

Question 17

What are PPOS

Answer 17

Type of MCO.

Affiliations of providers that seek contracts with insurance plans

Question 18

Explain PPO

Answer 18

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

Question 19

____ are a form of PPO that strictly limits participation among providers

Answer 19

EPOS

Question 20

Explain hybrid plans

Answer 20

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

Question 21

Are PBMS considered MCOs?

Answer 21

NO — but they have many characteristics of managed care (including a network)

Question 22

PBMS contract with a network of ___

Answer 22

Pharmacies

Question 23

What do PBMS use to compare network pharmacies

Answer 23

Report cards

Question 24

Who offers rebates to PBM? In exchange for what?

Answer 24

Manufactures offer rebates in exchange for placement on a formulary

Question 25

Who maintains an electronic data interchange for electronic claims submission, eligibility verification, and claims adjucation?

Answer 25

NCPDP (national council f prescription drug programs)

Question 26

Name 5 tiers on formularies

Answer 26

1-generics
2-preferred brands
3-nonpreferre brands
4-lifetstyledrugs
5-non formulary

Question 27

Prior authorizations are usually for ____ tier or below

Answer 27

Non preferred brand and below

Question 28

Name 4 ethical issues with MCOS

Answer 28

-financial incentives undermine the physicians role as an advocate and patient’s trust

-ethics of medicine replaced by ethics of business

-loss of physician autonomy

-limits patient choice

Question 29

Primarily, _______ departments have oversight of MCOs to ensure complicance with state laws and regulations

Answer 29

STATE INSURANCE DEPTS

Question 30

Name 3 major accrediting agencies

Answer 30

NCQA — national committee for quality assurance
URAC - utilization review accreditation commission
-JCAHO — joint commission for accreditation of healthcare orgs

Question 31

Who is the main accreditation agency for HMOs?
What about for PPOS?

Answer 31

HMO = NQA

PPO = URAC

Question 32

HEDIS

Answer 32

Health plan employer data and info set — used to evaluate MCOS n NCQA (primarily HMOs)