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Mgd Care/Integ Sys

Managed Care & Integrated Systems

What are the purpose of managed care & integrated systems? Utilization control & Cost-containment
Managed Care Single most dominant force in US HC delivery since 1990 Main driver: ability to control costs, which is why they were formed
Fee-For-Service before Managed Care Insured had free access to any provider, PCP or specialist Itemized billing of charges by provider to insurer Few controls over amount of payment Sickness coverage, no coverage for wellness/prevention Insurers fxned simply as passive payers of claims
Main Factors in the growth of managed care Flaws in fee-for-service (overused & abused) Cost appeal of managed care Weakened economic position of providers
Flaws in Fee-for-Service: Uncontrolled Utilization Moral hazard- if you don't have to pay, you use it more Overutilization of specialty care Provider-induced demand
Flaws in fee-for-service: Uncontrolled prices & payment Charges set at artificially high levels Insurers were passive payers of claims Inefficiencies absorbed by raising premiums
Flaws in fee-for-service: Focus on illness rather than wellness Lucrative for physicians to hospitalize pts
What is managed care? A mechanism of providing HC services where a single organization takes on the mgmt of: Financing, Insurance, Delivery, Payment (Quad Functions)
Integration of the Quad Functions Financing- negotiation b/t employers/MCOs Insurance- MCO assumes risk, need for insurance co. eliminated, risk often shared with providers Delivery- MCOs contract with providers Payment- capitation, discounted fees, salary
Capitation Provider paid a fixed monthly sum per enrollee, often called a per member, per month (PMPM) payment
Discounted Fees Modified form of fee-for-service Discounts off the regular fees often range b/t 25-35%
Who are MCOs accredited by? National Committee for Quality Assurance (NCQA) holds MCOs to standards Many MCOs voluntarily furnish cost & quality info through HEDIS report cards HEDIS data incorporate a # of different measures on cost & quality
Accreditation & Quality Indicators CMS rates Medicare Advantage (Part C) plans on a 1-5 star scale using indicators such as quality of care, access, responsiveness, & beneficiary satisfaction
Health Maintenance Organization Act of 1973 Passed to provide alternative to fee for service by stimulating growth of HMOs
Now, managed care & private health insurance Managed care is now the primary vehicle for delivering HC to majority of Americans
Managed Care & Medicare/Medicaid MC Advantage (Part C) gives beneficiaries the managed care choice Beneficiaries also have option to remain in fee for service (75% elected FFS option) >70% Medicaid enrolled in managed care plans nationwide Medicaid beneficiaries can enroll w/o waivers
Managed care evolved quite differently than what it was originally intended to be. Compromises made: Utilization mgmt relaxes (leniency to see diff providers) FFS payment incorporated along with capitation (cap on how much they would pay) Greater choice of providers offered (started letting in more providers)
MCOs 3 main types of controls Expert eval of medically necessary services Determination of how services can be provided most inexpensively (OP vs IP, etc) Review course of medical tx (when pt is in hospital)
Gatekeeping PCP coordinates all health services needed by enrollee (referral req'd if above basic service needs) Emphasizes preventive care, routine physicals, & other primary care services Higher levels of services obtained on basis of referral from PCP
Utilization Review Process of evaluating appropriateness of services provided
Types of Managed Care Organizations HMOs- gatekeeper: staff model, group model, network, model, independent practice association model (IPA) PPOs- list of in-network providers you can see for services Point-of-Service Plans (POS)
Three factors critical in differentiating b/t types of MCOs Choice of providers Different ways of arranging services Payment & risk-sharing (cost-sharing)
HMOs First type of managed care to appear on market Can only use in-network providers Gatekeeping Specialty services require referral Some FFS Risk sharing with providers under capitation Focus on prevention/primary care
PPOs Can use in and out of network providers as long as there is a contract No gatekeeping Unrestricted use of specialists Providers paid according to discounted fee schedules No risk sharing
POS Plans Can use in and out of network as long as they're contracted Unrestricted use of specialists Combination of capitation & FFS Some risk-sharing
HMO Staff Model Employs fixed salaried physicians End of year: $ distributed among physicians in form of bonuses, based on physician productivity & HMO's profitability Greater control over practice patterns Least popular- high operating expenses, limited provider choi
HMO Group Model Multi-specialty group practice & separately with 1+ hospitals, to provide comprehensive services to its members Physicians employed by practice, not HMO HMO pays all-inclusive capitation fee to practice to provide physician services to its enrollees
HMO Network Model Contracts with >1 medical group Adaptable to large metro areas, widespread geographic regions Group practices responsible for providing all physician services Offer more choice Disadvantage: dilution of utilization control Network more spread out
HMO IPA Model Most successful in terms of enrollment Contracts with solo & group practices Fxns in intermediary representing many physicians Disadvantage: contract lost, HMO loses large percentage of participating physicians
PPOs Instead of capitation, PPOs make discounted fee arrangements with providers Discounts range b/t 25-35% off providers' regular fees
POS Plans Combined features of HMOs with pt choice found in PPOs POS overcome restricted provider choice but retain benefits of tight utilization Free choice of providers- major selling point
Primary responsibility for cost containment falls on? Private sector In other nations, govt's control costs by limiting services & payments to providers
Impact on Access Managed care enrollees usually have good access to primary care, preventive services & health promotion activities HMO enrollees experience fewer disparities in access & utilization
Influence on Quality of Care Comprehensive studies show roughly = quality of care in HMO vs non-HMO; quality has improved over time Race, ethnicity, SES have little/no effect on quality Exceptions: satisfaction ratings; for-profit vs non-profit; quality isn't consistent in all MCO
Integrated Systems- No MCOs Formed in reponse to growing power of managed care Orgs had pressure to reduce costs, which was hard for small providers Integration into network became rational choice for survival Forming as result of ACA 2010 Not many private dr. practices
Integrated Delivery System Integration of several orgs under same ownership Provides array of HC services to large community
Fully integrated health network typically includes 1+ acute care hospitals Ambulatory care facilities 1+ physician group practices 1+ long-term care facilities Home health services Ownership/contract with 1+ MCOs (for payment of services)
Accountable Care Orgs Integrated groups of providers who takes responsibility for improving overal health status, efficiency, & satisfaction with care for a defined population
Concluding Points Health network emerged as hospitals & physicians faced pressure from managed care to cut costs; Integration allowed large health orgs to win sizeable insurance plans; Integrating physicians into large orgs challenging (want dr's to work more for less $)
Created by: 1190550002



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