QUIZ%205%20PREP - PREP FOR QUIZ #5: -also see highlighted...

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PREP FOR QUIZ #5: --also see highlighted issues below - reimbursement methods under managed care - types of utilization review under managed care - what led to development of MCOs and what are the main characteristics of each type (HMOs, PPOs, POS) - expansion of hospital services through horizontal and vertical integration - HMOs in relationship with physicians (employed or not) - LTC services—what categories of illnesses are these targeted to (chronic conditions), who provides the bulk of services (family and friends), basic goals of LTC services in the community - who pays for most of the nursing home care in the US - use of ADL and IADL scales to assess function in LTC CHAPTER 9: Managed Care and Integrated Systems OBJECTIVES OF MANAGED CARE To control the growth of health care expenditures by managing 1. Utilization of services, and 2. Reimbursement to providers MAIN CHARACTERISTICS OF MANAGED CARE Managed care is characterized by the management of financing, insurance, delivery, and payment functions in health care delivery. 1. Premium negotiations with the sponsors of health insurance (employers, government, etc.). 2. Assume insurance risk and in some cases share the risk with providers. 3. Enroll groups of members (or enrollees) and be responsible for obtaining health care services for them. 4. Manage utilization of health care. 5. Negotiate payment arrangements with providers. PAYMENT ARRANGEMENTS Capitation (PMPM) – providers share the most risk in this arrangement Discounted fees – fees are negotiated at discounts ranging between 25% and 35% off the regular charges established by the provider. Hence, risk sharing is minimum. Salaries – Some very large MCOs operate their own clinics and employ physicians on salary (staff HMOs). Bonuses are tied to utilization patterns, which allow some risk sharing. CONCERNS ABOUT QUALITY Utilization controls and risk sharing have raised concerns about quality or skimping on needed medical care.
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MCOs may seek voluntary accreditation by the National Committee for Quality Assurance (NCQA). MCOs can also voluntarily report their performance on cost and quality measures using the Health Plan Employer Data and Information Set (HEDIS). Reporting is required by some states. EVOLUTION AND GROWTH OF MANAGED CARE Contracts between physicians and some railroad, mining, and lumber companies based on a flat fee per worker (capitation) existed in the early 1900s. The first hospital insurance plan for teachers started at the Baylor University Hospital also used a capitation arrangement. Capitation was used in the 1940s by some large health plans in New York, California, Washington state, and St. Louis. The Health Maintenance Organization Act of 1973 was passed out of concern for escalating health care costs. The law was intended to provide an alternative to fee for service by stimulating the growth of HMOs. By the 1980s, employers could no longer afford to carry the burden of increasing health
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This note was uploaded on 01/12/2011 for the course HAP 301 taught by Professor Henderson during the Fall '10 term at George Mason.

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QUIZ%205%20PREP - PREP FOR QUIZ #5: -also see highlighted...

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