Liberman1 - Managed Care Managed Aaron Liberman, Ph.D....

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Managed Care Managed Care Aaron Liberman, Ph.D.
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Overview of Managed Care Overview of Managed Care
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Techniques of Managed Care vs. Techniques of Managed Care vs. Organizations Performing Organizations Performing Managed Care Functions Managed Care Functions Techniques Financial incentives for providers Promotion of wellness Early identification of disease Patient education Self-care Utilization management (UR, QI, QM)
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Techniques of Managed Care vs. Techniques of Managed Care vs. Organizations Performing Organizations Performing Managed Care Functions Managed Care Functions Organizations HMO PPO EPO POS Plan Specialty HMO Managed Care Overlay to Indemnity Plan PHO
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Stages of Managed Care Stages of Managed Care Early Years: Before 1970 1792 Shippers of Boston 1910 Western Clinic of Tacoma Wash. 1929 Baylor Hospital’s Prepaid Plan for Teachers (BCBS) 1932 AMA Adopts Stand Anti-Prepaid Group Practices
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Stages of Managed Care Stages of Managed Care Early Years: Before 1970 (cont.) 1937 Kaiser Foundation Health Plans 1937 Group Health Association 1944 HIP of New York 1947 Group Health Coop of Puget Sound 1954 First Individual Practice Association
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Stages of Managed Care Stages of Managed Care Early Years: Before 1970 (cont.) Trends Providers wanted to ensure flow of Employers began using prepaid plans Consumers sought access to improved & affordable healthcare
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Stages of Managed Care Stages of Managed Care Adolescent Years: 1970-1985 1973 HMO Act Problems with Federal Legislation
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Features of the 1973 HMO Act Features of the 1973 HMO Act Grants and loans to start HMOs State laws against HMO s overridden Dual choice provisions Indemnity vs. HMO Employers with 25+ employees must offer 2 HMO plans for every indemnity plan offered
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Features of the 1973 HMO Act Features of the 1973 HMO Act Process to become federally qualified Minimum benefit package Adequate provider network QA system in place Standards of financial stability Enrollee grievance system
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1973 HMO Act: Importance of 1973 HMO Act: Importance of Federal Qualification Federal Qualification Good Housekeeping Seal Use as a marketing tool Dual choice = access to employer market Preemption of state insurance oversight Required for receipt of federal grants
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1973 HMO Act: Problems with 1973 HMO Act: Problems with Federal Legislation Federal Legislation Compromise between Liberals & Conservatives in Congress Liberals wanted National Health Insurance Goal was to increase access to those without access Conservatives wanted competition Goal was to promote plans which gave physicians incentives to constrain costs
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1973 HMO Act: Problems with 1973 HMO Act: Problems with Federal Legislation Federal Legislation Result of the compromise was an
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Liberman1 - Managed Care Managed Aaron Liberman, Ph.D....

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