Podcast
Questions and Answers
What does managed health care combine?
What does managed health care combine?
- Health care delivery
- Financing of services
- Both A and B (correct)
- None of the above
What was the intent of managed care?
What was the intent of managed care?
To replace conventional fee-for-service plans with more affordable quality care.
What are some components included in the administration of managed care?
What are some components included in the administration of managed care?
Managed care organizations, managed care models, consumer-directed health plans, accreditation of managed care organizations.
Who is responsible for the health of a group of enrollees in a managed care organization?
Who is responsible for the health of a group of enrollees in a managed care organization?
What does a fee-for-service plan do?
What does a fee-for-service plan do?
How is managed care financed?
How is managed care financed?
What are pre-established payments for providing health care services called?
What are pre-established payments for providing health care services called?
From whom do managed care plan enrollees receive care?
From whom do managed care plan enrollees receive care?
What is the responsibility of a primary care provider (PCP)?
What is the responsibility of a primary care provider (PCP)?
What is a gatekeeper in the context of managed care?
What is a gatekeeper in the context of managed care?
What does a quality assurance program assess?
What does a quality assurance program assess?
What does EQRO stand for?
What does EQRO stand for?
Name independent organizations that perform quality reviews.
Name independent organizations that perform quality reviews.
What is QISMC?
What is QISMC?
What is utilization management?
What is utilization management?
What is a utilization review organization (URO)?
What is a utilization review organization (URO)?
What does a third-party administrator (TPA) do?
What does a third-party administrator (TPA) do?
What is case management?
What is case management?
What does the case manager submit to the provider?
What does the case manager submit to the provider?
What are gag clauses?
What are gag clauses?
What are physician incentives?
What are physician incentives?
What is required of managed care plans that contract with Medicare or Medicaid?
What is required of managed care plans that contract with Medicare or Medicaid?
How can managed care be categorized?
How can managed care be categorized?
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Study Notes
Managed Health Care Overview
- Managed care integrates service financing with healthcare delivery to create a coordinated approach to patient care.
- Designed to provide more affordable quality care, managed care replaces traditional fee-for-service models with cost-effective strategies.
Managed Care Organizations
- Managed Care Organizations (MCOs) can include health plans, hospitals, physician groups, or health systems, overseeing the health of their enrollees.
- The administration of managed care encompasses various models such as Consumer-Directed Health Plans and accreditation processes.
Financing and Payment Models
- Managed care employs capitation, where providers receive pre-established payments for a year's worth of services, incentivizing them to manage costs effectively.
- Fee-for-service plans reimburse providers per individual service rendered, contrasting capitation arrangements.
Primary Care Providers
- Enrollees in managed care select a primary care provider (PCP) from a specified list, who acts as a gatekeeper, managing referrals and ensuring coordinated care.
- The PCP is tasked with coordinating services and approving specialist referrals, with exceptions in emergencies.
Quality Assurance and Management
- Quality assurance programs assess care quality within healthcare settings, enabling continuous improvement via external reviews.
- Accreditation agencies, like the National Committee for Quality Assurance, perform independent evaluations to uphold standards.
Utilization Management
- Managed care plans apply utilization management to control costs and maintain care quality, often facilitated by utilization review organizations (UROs).
- A third-party administrator (TPA) handles claims administration and outsourced services for self-insured companies.
Case Management and Treatment Authorization
- Case management develops patient care plans for complicated medical cases, aiming for effective and cost-efficient care delivery.
- The case manager is responsible for providing written authorizations for treatment, facilitating necessary care interventions.
Physician Incentives and Gag Clauses
- Physician incentives are financial motivations for providers to limit or reduce services, which may impact patient care.
- Gag clauses restrict providers from discussing all treatment options with patients, affecting informed decision-making.
Regulatory Requirements
- Managed care plans contracting with Medicare or Medicaid must disclose physician incentive plans to regulatory agencies, ensuring transparency in healthcare contracts.
Types of Managed Care Models
- Managed care can be categorized into various models, including Exclusive Provider Organizations (EPOs), Integrated Delivery Systems (IDS), Health Maintenance Organizations (HMOs), and Preferred Provider Organizations (PPOs), among others.
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