US Healthcare System

Question 1

Why are negotiations of price made for managed care organizations?

Answer 1

shifts risks to provider by reducing provider induced demand

Question 2

what are the goals of primary managed care?

Answer 2

efficiency 
cost effectiveness
quality of services
continuity of care
Facilitate “Seamless Care” and “Care Transitions”

Question 3

how does managed care control costs?

Answer 3

Focusing on primary care + prevention
Chronic disease management
Restricting choice 
Limiting payment
Close utilization review

Question 4

how do restrictions on managed care plans affect costs?

Answer 4

least restrictive plan the higher the cost of the plan

more restrictive, lower cost

Question 5

what is Utilization Review (UR) in managed care?

Answer 5

Process for evaluating the appropriateness of services

Example: Case manager reviews each stay & each d/c plan to determine approp (and cost saving) level of service + next level of care

Question 6

what are the 3 types of utilization review (UR)?

Answer 6

prospective, concurrent, retrospective

Question 7

what is practice profiling?

Answer 7

Utilization Review (UR) tool that compares providers & individual practice pattern to a norm

Question 8

Health maintenance organizations tend to…

Answer 8

emphasize prevention, use capitation, maintain tight UR control

Question 9

what do preferred provider organizations (PPO) offer?

Answer 9

preferred providers discounted fees in anticipation of increased volume
Typically less UR monitoring than HMOs
BUT difficult for providers to get on PPO list

Question 10

what are features of Point of service plans (POS)?

Answer 10

Combines the features of open panel HMO and PPO.

Have gatekeepers, but not required to access gatekeeper to get to specialist

Question 11

what are care plans from least restrictive to most restrictive?

Answer 11

1. traditional indemnity insurance
2. PPO*
3. POS*
4. HMO*

*=managed care

Question 12

what does traditional indemnity service provide?

Answer 12

Provider reimbursed for each visit, procedure, service
Patient can visit provider of choice
Full choice, No restrictions
Very high premiums

Question 13

what does PPO service provide?

Answer 13

Provider reimbursed for each visit, procedure, service
Provider in network accepts discounted rate
Patient can visit provider outside of network but has higher copay and deductibles
Moderate premiums

Question 14

what does POS service provide?

Answer 14

Provider in network receives capitiated payment
Primary MD acts as gatekeeper or patient can self-refer
Patient can visit provider outside of network but copayments and deductibles apply
Moderate premuims

Question 15

what does HMO service provide?

Answer 15

Provider in network receives capitiated payment

• Patient must have referral to see specialist or go to hospital
• Patient must stay in network
• Low premiums

Question 16

what are some Special Considerations for Individuals with Chronic Illnesses/ Disabilities?

Answer 16

Not the “ideal” enrollee
Narrow medical necessity
Limited specialists to refer 
Delays in authorization
Limited LTC needs, disease course
Rigid disease management strategies

Question 17

what are clinical pathways especially designed for?

Answer 17

diagnosis/procedures that are
high volume
high risk
high cost

Question 18

what do clinical pathways provide?

Answer 18

standardized care plans

Should provide quality, coordinated, effective and efficient service

Used by some as marketing tool

Question 19

what does the NYS managed care bill of rights advise for enrollees?

Answer 19

Know what health care is given by plan, limits on care, types of health care not covered;

- txs or health care which needs to be approved in advanced 
- steps to take if plan won't cover service

Question 20

what is an ACO?

Answer 20

single health care entity forms integrated networks with other providers to share..

1. responsibility of a group of pts
2. accountability for improving outcomes and services, cost-effectively

Question 21

what is the difference btwn and HMO and an ACO?

Answer 21

ACO: pts don’t have to stay in specific network of providers instead retains a choice of provider

Question 22

what is the OT’s role in ACO’s?

Answer 22

reduce costs and support quality by adapting home environment and enhance a client’s functioning which will keep patients in the home

Question 23

what increases risk to provider?

Answer 23

capitation

Question 24

what does the gatekeeper control?

Answer 24

gatekeeper controls extra referrals to specialist (less referrals = less cost)