HSA 3111 - Week Nine Managed Care 2010

HSA 3111 - Week Nine Managed Care 2010 - MANAGED CARE...

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Unformatted text preview: MANAGED CARE MANAGED CARE PLANS COMBINE THE DELIVERY OF HEALTH CARE WITH THE FINANCING OF THAT CARE. IN A MANAGED CARE PLAN, SUCH AS A HEALTH MAINTENANCE ORGANIZATION (HMO) OR A PREFERRED PROVIDER ORGANIZATION (PPO), YOU RECEIVE YOUR HEALTH CARE FROM A GROUP OF PHYSICIANS, HOSPITALS, AND OTHER SERVICE PROVIDERS SELECTED BY THE PLAN. IN EXCHANGE, YOU PAY A SET MONTHLY FEE FOR THE SERVICES YOU RECEIVE. Goals of Managed Health Care Plans Provide high quality care in an environment that controls cost Care is medically necessary and appropriate Goals (Continued) Care is rendered by the most appropriate provider Care is rendered in the most appropriate, least-restrictive environment TYPES OF MANAGED CARE PLANS HEALTH MAINTENANCE ORGANIZATION GROUP AND STAFF MODEL HMOS ARE THE MOST RESTRICTIVE AND PROVIDE FEWER CHOICES OF PROVIDERS TO CONSUMERS. ON THE OTHER HAND, THIS MODEL OFTEN OFFERS ONE- STOP CARE WHICH MEANS THAT ALL YOUR DOCTORS, AS WELL AS LABORATORY AND X- RAY SERVICES ARE X-RAY SERVICES ARE LOCATED IN ONE MEDICAL FACILITY. IN A GROUP OR STAFF HMO, YOU MUST CHOOSE A PRIMARY PHYSICIAN. IF YOU DONT, THEY WILL CHOOSE ONE FOR YOU. INDIVIDUAL PRACTICE ASSOCIATONS (IPAS) INDIVIDUAL PRACTICE ASSOCIATIONS (IPAS) ARE A LESS RESTRICTIVE FORM OF HMO THAN THE GROUP OR STAFF MODEL. INDIVIDUAL PHYSICIANS PRACTICING IN THEIR OWN OFFICES ARE UNDER CONTRACT TO A SEPARATE GROUP, CALLED AN IPA THAT, IN TURN, CONTRACTS WITH AN HMO. THE HMO PROVIDES YOU WITH A LIST OF PARTICIPATING PHYSICIANS FROM WHICH YOU MAY CHOOSE YOUR PRIMARY CARE DOCTOR. VISITS TAKE PLACE IN THE DOCTORS OFFICE. IF YOU REQUIRE SPECIALITY CARE, YOUR PRIMARY CARE DOCTOR REFERS YOU TO A PARTICIPATING SPET. BY FAR THE LARGEST NUMBER OF HMO MEMBERS ARE ENROLLED IN THE IPA MODEL. PHYSICIANS MAY BELONG TO MORE THAN ONE HMO AND ALSO MAY CONTINUE TO SEE FEE-FOR-SERVICE PATIENTS IN THEIR OFFICE. POINT OF SERVICE (POS) POINT OF SERVICE (POS) PLANS PERMIT MEMBERS GREATER CHOICE AND FLEXIBILITY BY ALLOWING YOU THE OPTION OF GOING OUT OF PLAN TO USE NON-HMO PROVIDERS. IF YOU GO OUT OF PLAN, YOU MUST PAY MORE, TYPICALLY IN THE FORM OF HIGH COINSURANCE AND DEDUCTIONS. PREFERRED PROVIDER ORGANIZATION (PPO) PREFERRED PROVIDER ORGANIZATION (PPO) ARE NETWORKS OF DOCTORS AND HOSPITALS THAT HAVE AGREED TO GIVE THE SPONSORING ORGANIZATION DISCOUNTS ON THEIR USUAL RATES. (USUALLY AN EMPLOYER OR INSURANCE COMPANY). SOME PPOS USE PRIMARY CARE PHYSICIANS AS GATEKEEPERS. IN OTHERS, YOU MAY CHOOSE YOUR OWN DOCTORS AND VISIT SPETS WITHOUT PERMISSION FROM A GATEKEEPER. PPOS OFFER YOU THE GREATEST FREEDOM AMONG MANAGED CARE PLANS IN SELECTING HEALTH CARE PROVIDERS BUT PPO PREMIUMS ARE USUALLY SOMEWHAT HIGHER THAN HMO PREMIUMS AND THERE IS LESS COORDINATION OF CARE. DEFINED CARE Employer sponsored Defined Contribution Health plans....
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This note was uploaded on 07/18/2011 for the course HSA 3111 taught by Professor Lytle during the Fall '08 term at University of Florida.

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HSA 3111 - Week Nine Managed Care 2010 - MANAGED CARE...

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