Health Care Delivery Chapter 3 Flashcards

Questions and Answers

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?

To replace conventional fee-for-service plans with more affordable quality 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?

A managed care organization (MCO). Signup and view all the answers

What does a fee-for-service plan do?

Reimburse providers for individual health care services rendered. Signup and view all the answers

How is managed care financed?

According to a method called capitation. Signup and view all the answers

What are pre-established payments for providing health care services called?

Capitation. Signup and view all the answers

From whom do managed care plan enrollees receive care?

A primary care provider selected from a list of participating providers. Signup and view all the answers

What is the responsibility of a primary care provider (PCP)?

Supervising and coordinating health care services for enrollees. Signup and view all the answers

What is a gatekeeper in the context of managed care?

The primary care provider (PCP) serves as a gatekeeper. Signup and view all the answers

What does a quality assurance program assess?

The quality of care provided in a health care setting. Signup and view all the answers

What does EQRO stand for?

External quality review organization. Signup and view all the answers

Name independent organizations that perform quality reviews.

Accreditation agencies such as the National Committee for Quality Assurance and The Joint Commission. Signup and view all the answers

What is QISMC?

Quality Improvement System for Managed Care. Signup and view all the answers

What is utilization management?

A method of controlling health care costs and quality of care. Signup and view all the answers

What is a utilization review organization (URO)?

An entity that establishes a utilization management program and performs external utilization review services. Signup and view all the answers

What does a third-party administrator (TPA) do?

Provides health benefits claims administration and other outsourced services for self-insured companies. Signup and view all the answers

What is case management?

Patient care plans for the coordination and provision of care for complicated cases in a cost-effective manner. Signup and view all the answers

What does the case manager submit to the provider?

Written confirmation, authorizing treatment. Signup and view all the answers

What are gag clauses?

Clauses that prevent providers from discussing all treatment options with patients. Signup and view all the answers

What are physician incentives?

Payments made directly or indirectly to health care providers to encourage reducing services. Signup and view all the answers

What is required of managed care plans that contract with Medicare or Medicaid?

To disclose information about physician incentive plans to CMS or state Medicaid agencies. Signup and view all the answers

How can managed care be categorized?

By six models Signup and view all the answers

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.

Studying That Suits You

Use AI to generate personalized quizzes and flashcards to suit your learning preferences.

Description

Test your understanding of managed health care concepts with these flashcards from Chapter 3. This set covers important terms and definitions relevant to health care delivery and managed care organizations. Perfect for students looking to boost their knowledge in this key area of health care.