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managed care
| Question | Answer |
|---|---|
| since around 1990, what has been the single most dominant force in the U.S. health care delivery | managed care |
| what has experienced unprecedented success | managed care |
| What is the main driver about managed care | ability to control costs--designed to help condense or manage costs |
| Managed care organizations (MCOs) garnered enormous buying power by doing what? | -enrolling a large segment of the insured population -taking responsibility to produce cost-effective health care for enrollees |
| Organizational int egration and formation of alliances by providers was in response to what | managed care |
| Organizational integration gave rise to what | medical systems partnerships b/t physicians and hospitals integrated delivery systems (health networks) |
| What was the system before managed care | Fee-for-Service |
| Fee-for-service before managed care | -insured had free access to any prov, PCP, or specialist -itemized billing of chrgs by the prov to the insurer -Few, if any controls over the amount of pymt -Sick cov; no cov for wellness and prevention -Insurers functioned simply as pass payers of cl |
| Main factors to the growth of managed care | Flaws in fee-for-service Cost appeal of managed care Weakened economic position of providers |
| Flaws in Fee-for-service | Uncontrolled utilization Uncontrolled prices and payment Focus on illness rather than wellness |
| Uncontrolled utilization | Moral hazard Uncontrolled prices and payment Focus on illness rather than wellness |
| What is moral hazard | going to the DR b/c you have a low co-pay not necessarily b/c they need it |
| Uncontrolled prices and payment | Charges set at artificially high levels Insurers were passive payers of claims Inefficiencies absorbed by raising premiums |
| Focus on illness rather than wellness | Lucrative for physicians to hospitalize pts |
| What is managed care | mechanism of providing health care services where a single org. takes on management of: -financing -insurance -delivery -payment |
| What are the Quad functions | Financing Insurance Delivery Payment |
| Quad functions: financing | contract negotiations b/t employers and MCOs (for their employees) |
| Quad functions: Insurance | The MCO assumes risk Need for an insurance company is eliminated Risk is often shared w/ providers |
| Quad functions: delivery | comprehensive array of services. Most MCOs contract w/ providers |
| Quad functions: Payment--how is it controlled | Capitation Discounted fees Physician salaries |
| MCOs exercise formal control over what | the utilization of health care services |
| Most common methods used for reimbursing providers? | Capitation Discounted fees |
| What is Capitation | provider is paid a fixed monthly sum per enrollee, often called a per member, per month payment (PMPM) |
| Discounted Fees | A modified form of fee-for service Discounts off the regular fees often range b/t 25-35% |
| MCOs are accredited by who | National Committee for Quality Assurance (NCQA) |
| Many MCOs voluntarily do what | furnish cost and quality information through HEDIS report cards |
| HEDIS data incorporate what | a number of different measures on cost and quality |
| The CMS rates Medicare Advantage (part C) on what? | 1 to 5 star scale using indicators such as: -quality of care -access -responsiveness -beneficiary satisfaction |
| In early 1900s what occurred | railroad, mining and lumber companies employed salaried physicians to provide care |
| The Health Maintenance Organization Act 1973 was passed to provide what | an alternative to fee for service by stimulating the growth of HMOs |
| As managed care grew, what occurred | competition among MCOs gave rise to new forms of managed care plans |
| Managed care is implemented in what type of insurance | Medicare and medicaid |
| What are commonly in the form of managed care plans | HDHPs |
| Medicare Advantage (Part C) | gives beneficiaries the managed care choice |
| Medicaid waivers are under what act | Social Security Act |
| What did the Balance budget act of 1997 do | gave states authority to enroll beneficiaries in managed care w/out waivers |
| what % of medicaid ind. are enrolled in managed care plans nationwide | 70% |
| Compromises made in 1990s after a backlash | utilization management was relaxed Fee-for-service payment was incorporated along w/ capitation (instead of getting rid of it all together) Greater choice of providers was offered |
| MCOs 3 main types of control | 1. Expert eval of what services are medically necessary 2. Determination of how services can be provided (oupt v. inpt) 3. Review the course of med tx (e.g. when a pt is in a hospital) |
| Utilization control methods in managed care | Gateskeeping Utilization Review--prospective utilization, concurrent utilization, retrospective utilization reviews |
| Who is the gateskeeper for HMO plans | Primary Physician--determines what care the pt gets--coordinates all health services needed by an enrollee |
| Gatekeeping emphasizes what | preventive care, routine physical exams, and other primary services |
| Higher levels of services are obtained how | on the basis of referral from the PCP |
| Utilization review | process of evaluating the appropriateness of services provided |
| 3 types of utilization review | Prospective utilization review concurrent utilization review retrospective utilization review |
| Prospective utilization review | Medical necessity for certain tx is determined before the care is delivered |
| Main objectives of prospective utilization review | to prevent unnecessary or inappropriate institutionalization or txs such as surgery |
| Concurrent utilization review | appropriateness is determined during the course of health care utilization |
| Most common example of concurrent utilization review | monitoring the length of inpatient stays |
| Discharge planning and what go hand in hand | concurrent review |
| Retrospective utilization review | managing utilization after services have already been delivered |
| retrospective utilization review is based on what | examination of med records to assess the appropriateness of care |
| Retrospective utilization review examines what | overutilization and underutilization |
| Types of MCOs | HMOs PPOs Point-of-Service Plans (POS) |
| HMOs | Staff Model Group Model Network Model Independent Practice Association (IPA) Model -they differ according to the arrangements made w/ participating physicians |
| 3 factors critical in differentiating b/t the types of MCOs | -choice of providers -Different ways of arranging services -Payment and risk-sharing |
| First type of managed care plans to appear on the market | HMOs |
| HMOs: Staff Model | employs its own fixed salaried physicians -at the end of the year, pool of money is distributed among the physicians in the form of bonuses, based on each physician's productivity and the HMOs profitability |
| Which HMO model exercises greater control over practice patterns and can better monitor utilization | Staff Model |
| What HMO model is the least popular | Staff Model--continues to decline b/c of high operating expenses and limited choice of providers |
| HMOs: Group model contracts w/ what | w/ a multispecialty group practice and separately w/ one or more hospitals, to provide comprehensive services to its members |
| HMOs: group model, employed how | physicians employed by the practice, not the HMO |
| HMOs: group model | HMO pays an all inclusive capitation fee to the practice to provide physician services to its enrollees |
| HMO: network model | HMO contracts w/ more than one medical group practice |
| What HMO model is adaptable to large metropolitan areas and widespread geographic regions | Network model |
| HMO: network model--offers more or limited choices | more choices |
| HMO: network model: group practices are responsible for what | providing all physician services |
| HMO: network model: disadvantage | dilution of utilization control |
| Which HMO model has been the most successful in terms of enrollment | Independent Practice Association (IPA) model |
| HMO: IPA model establishes what | contracts w/ solo and group practices |
| HMO: IPA model functions as what | an intermediary representing many physicians |
| HMO: IPA model disadvantage | If a contract is lost, the HMO loses a large % of participating physicians |
| Instead of capitation, PPOs do what | make discounted arrangements w/ providers--discounts range between 25%-35% off provider's regular fees |
| Point-of-Service plans (POS) combine what features | HMOs w/ patient choice found in PPOs |
| Point of service plans (POS) overcome what? Retain what? | overcome restricted provider choice but retain the benefits of tight utilization |
| What is a major selling point for POS plans | Free choice of providers |
| Why has POS plans declined | high out of pocket costs |
| In the U.S. primary responsibility for cost containment falls on? | the private sector |
| in other countries, how dos the government control costs | by limiting services and payments to providers |
| managed care successfully controlled cost during what time period? Why was this not sustained | 1990s; there was a backlash |
| Recent moderation of premium increases is attributed to what | increased cost sharing |
| managed care enrollees usually have GOOD or BAD access to primary care, preventive services, and health promotion activities | GOOD |
| HMO enrollees experience fewer disparities in what | access and utilization |
| What has little or no effect on quality under managed care | race, ethnicity, socioeconomic status |
| Exceptions to managed care | satisfaction ratings for-profit v. nonprofit MCOs Quality is not consistent in all MCO plans |
| integrated system was formed in response to what | growing power of managed care-- became a rational choice for the survival of small providers |
| Integration of several organizations under the same ownership | integrated delivery system (health network) |
| What does an integrated delivery system provide | an array of health care services to a large community |
| What does a fully integrated health network typically include | -one or more acute care hospitals -ambulatory care facilities -one or more physician group practices -one or more long-term care facilities -home health services -ownership or contract w/ one or more MCOs |
| Accountable Care Organizations | Integrated groups of providers who take responsibility for improving the overall health status, efficiency, and satisfaction w/ care for a defined pop |
| Accountable care organizations are authorized under what | ACA of 2010 |
| Types of integration | Integration based on major participants Integration based on ownership or affiliation Integration based on service consolidation |
| Integration based on ownership or affiliation | Acquisitions and mergers joint ventures alliances virtual organizations |
| integration based on service consolidation | horizontal integration vertical integration |
| Integration based on major participants | PHO |
| PHO is what | alliance b/t physicians and hospitals--together they have greater bargaining power w/ MCOs |
| Large PHOs contract w/ who | directly w/ employers |
| Why did many PHOs fail | After a surge in 1990s, decline b/c of poor management, undercapitalization, and federal scrutiny |
| Acquisition | purchase on one organization by another |
| Merger | two organizations join to form a single entity |
| Results achieved from acquisitions and mergers | Gain efficiencies Open new satellites Regional health systems |
| Integration on type of ownership and affiliation | Acquisitions and mergers Joint Venture Alliances |
| Joint Venture | a jointly created independent organization based on cooperation instead of competition helps the joint owners diversify into new services |
| Alliances | -based on agreements b/t 2 organizations -does not involve joint ownership of assets -Mainly involves resource sharing |
| Basic integration is a way of? | cost control |
| Alliances give an opportunity to evaluate what | advantages before a merger |
| requires little financial commitment | Alliances |
| What can be easily dissolved | alliances |
| Virtual Organizations | formation of new organizations based on contracts |
| Prime example of virtual organization | IPA |
| Main advantage of virtual organizations | little capital outlays are required |
| Integration based on service consolidation | horizontal integration Vertical integration |
| Horizontal integration | a growth strategy in which a health care delivery organization extends its core product or service |
| Main objective of horizontal integration? | to achieve geographic expansion |
| vertical organization | links services that are at different stages in the production process of health care |
| purpose of vertical organization | increase the comprehensiveness and continuity of care |
| A diversification strategy | vertical integration |
| How can vertical integration be achieved | through acquisitions, mergers, joint ventures, or alliances |
| Most Americans receive care through what | managed care--cost savings have veen achieved while quality is maintained |
| Health networks emerged as what | hospitals and physicians faced pressures form managed care to cut costs |
| integration allowed for what | allowed large health organizations to win sizeable insurance plans |
| Integrating physicians into large organizations: Easy or challenging? | challenging |
Created by:
Amusch21