US Healthcare System Flashcards
Why are negotiations of price made for managed care organizations?
shifts risks to provider by reducing provider induced demand
what are the goals of primary managed care?
efficiency cost effectiveness quality of services continuity of care Facilitate “Seamless Care” and “Care Transitions”
how does managed care control costs?
Focusing on primary care + prevention Chronic disease management Restricting choice Limiting payment Close utilization review
how do restrictions on managed care plans affect costs?
least restrictive plan the higher the cost of the plan
more restrictive, lower cost
what is Utilization Review (UR) in managed care?
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
what are the 3 types of utilization review (UR)?
prospective, concurrent, retrospective
what is practice profiling?
Utilization Review (UR) tool that compares providers & individual practice pattern to a norm
Health maintenance organizations tend to…
emphasize prevention, use capitation, maintain tight UR control
what do preferred provider organizations (PPO) offer?
preferred providers discounted fees in anticipation of increased volume
Typically less UR monitoring than HMOs
BUT difficult for providers to get on PPO list
what are features of Point of service plans (POS)?
Combines the features of open panel HMO and PPO.
Have gatekeepers, but not required to access gatekeeper to get to specialist
what are care plans from least restrictive to most restrictive?
- traditional indemnity insurance
- PPO*
- POS*
- HMO*
*=managed care
what does traditional indemnity service provide?
Provider reimbursed for each visit, procedure, service
Patient can visit provider of choice
Full choice, No restrictions
Very high premiums
what does PPO service provide?
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
what does POS service provide?
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
what does HMO service provide?
Provider in network receives capitiated payment
- Patient must have referral to see specialist or go to hospital
- Patient must stay in network
- Low premiums
what are some Special Considerations for Individuals with Chronic Illnesses/ Disabilities?
Not the “ideal” enrollee Narrow medical necessity Limited specialists to refer Delays in authorization Limited LTC needs, disease course Rigid disease management strategies
what are clinical pathways especially designed for?
diagnosis/procedures that are
high volume
high risk
high cost
what do clinical pathways provide?
standardized care plans
Should provide quality, coordinated, effective and efficient service
Used by some as marketing tool
what does the NYS managed care bill of rights advise for enrollees?
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
what is an ACO?
single health care entity forms integrated networks with other providers to share..
- responsibility of a group of pts
- accountability for improving outcomes and services, cost-effectively
what is the difference btwn and HMO and an ACO?
ACO: pts don’t have to stay in specific network of providers instead retains a choice of provider
what is the OT’s role in ACO’s?
reduce costs and support quality by adapting home environment and enhance a client’s functioning which will keep patients in the home
what increases risk to provider?
capitation
what does the gatekeeper control?
gatekeeper controls extra referrals to specialist (less referrals = less cost)
