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managed care setting
legal & ethical issues in nursing chap 18
| Question | Answer |
|---|---|
| Managed care organizations (MCOs) | Shift from domination of fee-for-service system, Process restructuring, Package of health care benefits, Prepaid or capitated |
| Health maintenance organization (HMO) | Comprehensive financing and services to a specified group of enrollees at a fixed periodic payment |
| Types of HMOs | Staff model, Independent practice association model, Group model, Network model |
| Preferred provider organization (PPO) | Significantly better benefits for services by preferred providers, Encourages use by enrollees |
| Point of service (POS) | Hybrid of HMO-PPO, Option of managed care program or out-of-plan services |
| Process whereby third-party payer evaluates the medical necessity of a course of treatment | Necessary part of cost containment, Must be done ethically and with caution |
| Utilization review of MCOs | 1989 Ethics in Patient Referral Act, National Committee for Quality Assurance |
| Employment Retirement Income Security Act (ERISA) | Ensures employee welfare benefit plans conform to a uniform body of benefits laws |
| Gag Rules and End-of-Year Profit Sharing | Prevents health care providers from offering certain more expensive therapies, Restricting services |
| Standards of Care | Duty to render quality care, Duty to select and retain competent primary care providers |
| Emergency Medical Treatment and Labor Act (EMTALA)1986 | Right to care regardless of ability to pay, Applies to emergency medical conditions and women in labor, Medical screening requirement, Stabilizing treatment |
| Antitrust Issues in Managed Care | Health care is dominated by large, for-profit centers, Antitrust laws promote competition while creating efficient markets |
| Patient Rights | Advisory Commission on Consumer Protection and Quality in the Health Care Industry |
| Eight areas of consumer rights | Information disclosure, Choice of providers and plans, Access to emergency services, Participation in treatment decisions, Respect and nondiscrimination, Confidentiality of health information, Complaints and appeals, Consumer responsibilities |
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