Managed Care Essays (2289 words) - Healthcare Quality, Managed Care

Managed Care Chapter 3: Types of Managed Care Organization ? The distinction between health care providers and health care insurers have blurred substantially ? 10 Years ago managed care organizations were often referred to as alternative delivery systems ? Managed care is now the dominant form of health insurance coverage in the United States ? Managed care can mean managing the provider delivery system can be equivalent in its outcomes to managing the medical care delivered to the patient ? Managed care may not perfectly describe this current generation of financing vehicles, it provides a convenient shorthand description for the range of alternatives to traditional indemnity health insurance ? On one end of the continuum is managed indemnity with simple pre-certification of elective admission and large case management of catastrophic cases, superimposed on a traditional indemnity insurance plan ? Further along the continuum are PPOs, POSs, open-panel [individual practice association (IPA) type] HMOs, and closed-panel (group and staff model) HMOs TYPES OF MANAGED CARE ORGANIZATIONS AND COMMON ACRONYMS HMOs ? HMOs are organized health care systems that are responsible for both the financing are the delivery of a broad range of comprehensive health services to an enrolled population ? HMO health insurer and a health care delivery system ? HMOs are responsible for providing health care services to their covered members through affiliated providers, who are reimbursed under various methods ? HMOs must ensure that their members have access to covered health care services ? HMOs generally are responsible for ensuring the quality and appropriateness of the health services they provide to their members ? The five common models of HMOs are (1) staff, (2) group practice, (3) network, (4) IPA, and (5) direct contact PPOs ? PPOs are entities through which employer health benefit plans and health insurance carriers contract to purchase health care services for covered beneficiaries from a selected group of participating providers ? PPOs often limit the size of their participating provider panels and provide incentives for their covered individuals to use participating providers instead of other providers ? In contrast to individuals with traditional HMO coverage individuals with PPO coverage are permitted to use non-PPO providers ? PPOs sometimes are described as preferred provider arrangements (PPAs) ? PPA is used to describe a less formal relationship than PPO ? The term PPO implies that an organization exists, whereas a PPA may achieve the same goals as a PPO through an informal arrangement among providers and payers ? Key common characteristics of a PPO include: ? Select provider panel ? Negotiated payment rates ? Rapid payment terms ? Utilization management ? Consumer choice Exclusive Provider Organizations ? Exclusive provider organizations (EPOs) limit their beneficiaries to participating providers for any health care services ? The EPO generally does not cover services received from other providers, although their may be exceptions ? EPOs, like HMOs, require exclusive use of the EPO provider network and also use a gatekeeper approach to authorizing non-primary care services ? The difference between an HMO and an EPO is that the former is regulated by HMO laws and regulations, and the latter is regulated under insurance laws and regulations ? Employee Retirement Income Security Act of 1974 ? EPOs usually are implemented by employers (b/c it's cost efficient) POS Plans ? Hybrids of HMO and PPO models ? Characteristics include: ? Primary care physician are reimbursed through capitation payments (i.e. Fixed payment per member per month) ? An amount is with held from physician compensation that is paid contingent upon achievement of utilization or cost targets ? The primary care physician acts as a gatekeeper for referral and institutional medical services ? The member retains some coverage for services rendered that either are not authorized by the primary care physician or are delivered by non-participating providers Open Access or POS HMOs ? Provides some level of indemnity-type coverage along with the HMO coverage ? HMO members covered under these types of benefit plans may decide whether to use HMO benefits or indemnity-style benefits for each instance of care ? The member is allowed to make coverage choice at the point of service when medical care is needed ? Most POS plans experience between 65 percent and 85 percent in-network usage, thus retaining considerable cost control compared to indemnity-type plans ? There are two primary ways form an HMO to offer POS option 1) Via a single HMO license a. HMO provides the out-of-network benefit using its HMO license 2) Via a duel-license approach a. The health plan