Managed Care Flashcards

Questions and Answers

What is managed care?

A financial management system

A mechanism of providing health care services (correct)

A specific medical treatment

A type of insurance

Which of the following are common methods used for reimbursing providers?

Discounted fees (correct)

Flat-rate payment

Pay-for-performance

Capitation (correct)

What does capitation refer to?

Provider is paid a fixed monthly sum per enrollee.

MCOs are accredited by ________.

National Committee for Quality Assurance (NCQA) Signup and view all the answers

Many MCOs furnish cost and quality information through _________ report cards.

HEDIS Signup and view all the answers

CMS rates _________ plans on a 1 to 5 star scale.

Medicare Advantage (Part C) Signup and view all the answers

What was the purpose of The Health Maintenance Organization Act of 1973?

To provide an alternative to fee-for-service by stimulating growth of HMOs. Signup and view all the answers

What is gatekeeping in managed care?

A primary care physician coordinates all health services needed by an enrollee. Signup and view all the answers

What is the purpose of utilization review?

To evaluate the appropriateness of services provided. Signup and view all the answers

What is prospective utilization review?

Determining the medical necessity for treatments before care is delivered. Signup and view all the answers

What is concurrent utilization review?

Determining appropriateness during the course of health care utilization. Signup and view all the answers

What does retrospective utilization review involve?

Managing utilization after services have been delivered. Signup and view all the answers

What are HMOs?

The first type of managed care plans to appear on the market. Signup and view all the answers

What is the HMO Staff Model?

It employs fixed salaried physicians and distributes bonuses based on productivity. Signup and view all the answers

What is the HMO Group Model?

Contracts with multispecialty group practices for comprehensive services. Signup and view all the answers

What does the HMO Network Model involve?

Contracts with multiple medical group practices. Signup and view all the answers

What is the Point of Service (POS) model?

It combines features of HMOs with patient choice found in PPOs. Signup and view all the answers

What are integrated systems?

Organizations formed in response to managed care pressure to reduce costs. Signup and view all the answers

What is an integrated delivery system?

Integration of several organizations under the same ownership. Signup and view all the answers

What are accountable care organizations?

Integrated groups of providers responsible for improving health status and care satisfaction. Signup and view all the answers

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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Description

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.