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PPD 230 Midterm Review

PPD 230 Midterm Review - PPD 230 Midterm Review 1.What does...

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PPD 230: Midterm Review 1. What does HMO stand for? What does it do? - Health Maintenance Organization - Purpose: to control costs and encourage competition among health plans - A type of managed care organization - Capitation reimbursement - Assumes or shares financial risks and delivery risks to members in return for prepaid fee 2. What are the names of the four common HMO models? - Staff Model - Group Model - Network Model - Independent Practice Association (IPA) 3. Briefly describe the four common HMO models. - Staff Model - Employs MDs to provide services to its members - Some specialty services provided under contracted arrangement with HMO - HMO operates facilities where MDs practice - HMO contracts with hospital for inpatient services - Limited choice of MDs for patients - Group Model - HMO contracts with multispecialty group practice to provide care to members - MDs not employed by HMO but receive a negotiated per capita rate from HMO which the group distributes among the MDs on a salary basis - Network Model - HMO contracts with more than one medical group practice - Able to offer a wider choice of physicians than the staff or group models - Dilution of utilization control - Independent Practice Association (IPA) - A legal entity separate from the HMO - Establishes contracts with independent solo practitioners and group practices - Functions as an intermediary representing a large number of physicians - HMO is still responsible for providing healthcare services to its enrollee, but the logistics of arranging physician services are shifted to the IPA 4. How is healthcare paid for? - Financing is influenced by purchasers, employers, consumers, providers, and political factors - Purchasers obtain the coverage - Employers (as the purchaser) pays premium
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- Consumers pay deductible and co-pay - Providers are reimbursed by insurance - Political pressures stemming from rising costs and increased uninsured/underinsured population 5. Name 3 health policy issues and describe why they are considered issues. - Access to care: elderly, minorities, rural areas, low income; decreased access to care for patients because of insufficient coverage, financial, resources, etc. - Cost: increased cost for services - Public financing: coverage for the uninsured/underinsured population with tax funds 6. Describe a reimbursement method. - Fee for service: unbundled services and paid for separately - Doctor is paid for each individual service performed rather than as part of a comprehensive plan - The bill is made out by the MD, and is usually paid - Capitation: bundled charges (global fees); related services included in one price - Provider is paid a monthly fixed fee for each enrollee - The amount stays the same whether the patient comes in or not - Many MDs are forced to spend less time with capitated patients and more time with non-capitated “paying” patients; MDs resent this position - Medicare/Medicaid: prospective reimbursement (currently) to force hospitals to control cost 7.
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