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Unformatted text preview: 1 Managed Care Chap. 19, PLB October 12, 2010 AHS 330 - Unit 6 - Fall 2010 1 Overview • Definitions of managed care and different forms of managed care • Types of HMOs • Trends in managed care • Problems with managed care • Court rulings involving managed care October 12, 2010 AHS 330 - Unit 6 - Fall 2010 2 Managed Care • A term used to describe a variety/spectrum of approaches used to integrate the delivery and financing of health care • In managed care, both patient utilization and provider practices are managed by an entity that has a fiduciary interest in the interactions between them – An umbrellas term for a range of organizational and reimbursement mechanisms in the U.S. delivery system October 12, 2010 AHS 330 - Unit 6 - Fall 2010 3 Employer or individual pays premium to managed care company Managed Care Organization General Managed Care Process: contracts with Providers to care for specified period of time Patient seeks care from the primary care provider when necessary (may be referred to a spet if necessary); patient pays applicable co-payment October 12, 2010 AHS 330 - Unit 6 - Fall 2010 4 October 12, 2010 AHS 330 - Unit 6 - Fall 2010 5 Shifts From FFS to Managed Care • Focus shift – From individual provider ‐ patient to comprehensive needs of a population of patients – From episodic care to holistic care From episodic care to holistic care – From reimbursement on a fixed fee per service to a fixed fee for all services October 12, 2010 AHS 330 - Unit 6 - Fall 2010 6 2 Why a shift towards managed care? • Risings costs • Perverse incentive of FFS • Open access to spets • Need to better predict costs • Need for accountability • Need to increase efficiency • The societal burden of the uninsured October 12, 2010 AHS 330 - Unit 6 - Fall 2010 7 Essential Terms Associated With Managed Care • Gatekeeper—primary care physician (PCP) who must authorize all care before any care is rendered • Capitation—a set amount of money received/paid out; it is based on membership rather than on services delivered (common example is per member/per month) • Closed Panel—a managed care plan that contracts with physicians on an exclusive basis for services; the physicians do not treat any other patients besides those who are members of the plan. Can also refer to patients only being able to see physicians who are contracted or employed by the plan. • Open Panel—a managed care plan that contracts with private physicians to deliver care in their own offices; the physicians may see other patients that are not in the plan. Can also refer to patients being permitted to see physicians who are not contracted or employed by the plan October 12, 2010 AHS 330 - Unit 6 - Fall 2010 8 Essential Terms Associated With Managed Care • MCO – Managed Care Organization • HMO – Health Maintenance Organization • POS – Point of Service PPO Preferred Provider Organization • PPO – Preferred Provider Organization...
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This note was uploaded on 08/21/2011 for the course AHS 330 taught by Professor Smith during the Fall '10 term at University of Alabama at Birmingham.
- Fall '10