Questions and Answers
What is managed care?
Which of the following are common methods used for reimbursing providers?
What does capitation refer to?
Provider is paid a fixed monthly sum per enrollee.
MCOs are accredited by ________.
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Many MCOs furnish cost and quality information through _________ report cards.
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CMS rates _________ plans on a 1 to 5 star scale.
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What was the purpose of The Health Maintenance Organization Act of 1973?
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What is gatekeeping in managed care?
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What is the purpose of utilization review?
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What is prospective utilization review?
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What is concurrent utilization review?
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What does retrospective utilization review involve?
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What are HMOs?
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What is the HMO Staff Model?
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What is the HMO Group Model?
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What does the HMO Network Model involve?
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What is the Point of Service (POS) model?
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What are integrated systems?
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What is an integrated delivery system?
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What are accountable care organizations?
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Study Notes
Managed Care Terminology
- Managed care involves the management of financing, insurance, delivery, and payment in healthcare by a single organization.
- Capitation and discounted fees are prevalent reimbursement methods for healthcare providers.
Capitation
- A fixed monthly payment per enrolee, known as per member, per month (PMPM) payment, is established for providers under capitation.
Accreditation and Quality Assurance
- Managed Care Organizations (MCOs) are accredited by the National Committee for Quality Assurance (NCQA).
- Many MCOs provide quality and cost information using Health Effectiveness Data and Information Set (HEDIS) report cards.
Medicare Advantage
- Plans under Medicare Advantage (Part C) are rated on a 1 to 5 star scale by CMS using metrics like quality of care, access, and beneficiary satisfaction.
Legislative Background
- The Health Maintenance Organization Act of 1973 aimed to stimulate HMO growth as an alternative to fee-for-service models.
Gatekeeping and Utilization Review
- Gatekeeping involves a primary care physician coordinating all necessary health services, emphasizing preventive care.
- Utilization review assesses the appropriateness of provided services, categorized into prospective, concurrent, and retrospective reviews.
HMO Models
- HMOs were the first managed care plans and include several models:
- HMO Staff Model: Employs salaried physicians with productivity-based bonuses, offering high control over practice patterns but facing high operating costs.
- HMO Group Model: Contracts with multispecialty groups and hospitals, paying them an all-inclusive capitation fee.
- HMO Network Model: Contracts with multiple medical group practices, providing more physician choices but weaker utilization control.
Point of Service (POS)
- POS plans combine features of HMOs and PPOs, offering patient choice while retaining tight utilization controls.
Integrated Delivery Systems
- Integrated systems arose to combat managed care pressures, allowing small providers to survive by joining networks.
- An integrated delivery system merges multiple organizations under common ownership, delivering a wide range of healthcare services.
Accountable Care Organizations (ACOs)
- ACOs are composed of integrated provider groups that enhance health outcomes, efficiency, and patient satisfaction, as authorized by the Affordable Care Act (ACA) of 2010.
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Test your understanding of managed care and integrated delivery systems with these flashcards. Each card focuses on key terms and definitions important in the healthcare management field. Perfect for students and professionals looking to enhance their knowledge.