Managed Care Lecture part 1

Question 1

What is managed care?

Answer 1

An organized approach to deliver comprehensive svcs to a grp of enrolled members through efficient management of svcs and negotiation of prices with providers.=

Question 2

What are the 2 core features of managed care?

Answer 2

Integration of the 4 functions of a HC system
Formal control over utilization

Question 3

Role of managed care in financing

Answer 3

Negotiation of premiums with employers

Question 4

Role of managed care in insurance

Answer 4

The MCO assumes insurance risk

Question 5

Role of managed care in delivery

Answer 5

MCO’s own physicians and hospitals or contracts with providers

Question 6

Role of managed care in payment

Answer 6

Using 3 methods (capitation, discounted fees, salary) for risk sharing between the MCO and providers

Question 7

What were the main factors in managed care’s growth?

Answer 7

Flaws in fee for service
Employers’ response to rise in premiums
Weakened economic position of providers

Question 8

How did flaws in fee for service contribute to managed care’s growth?

Answer 8

Uncontrolled utilization d/t moral hazard and provider-induced demand
Uncontrolled prices and payment d/t itemized billing of charges by the provider to the insurer
-Insurers functioned simply as passive payers of claims
-Focus on illness rather than wellness: sickness coverage; no coverage for wellness and prevention; no control over costly hospitalizations

Question 9

Trends in employer’s response to rise in premiums

Answer 9

Annual increase in private insurance costs by over 12% between 1980-1990
Employer based insurance with managed care: 27% in 1988, 95% in 2003

Question 10

How did weakened economic position of providers contribute to managed care’s growth?

Answer 10

Excess capacity in hospitals brought on by the Medicare prospective payment system led to weakened bargaining power of hospitals
Physicians gave in to the momentum of managed care leading to participation or being left out

Question 11

Efficiencies in managed care

Answer 11

Eliminating insurance and payer intermediaries
Cost control through risk sharing with providers or extracting discounts from providers
Cost savings by coordinating pt svcs and monitoring the delivery of svcs for appropriateness
Gatekeeping to reduce moral hazard
Saving money through illness prevention and early detection and tx

Question 12

Inefficiencies in managed care

Answer 12

Complexity for providers of having to deal with numerous plans
Carved out laboratory and other services are creating inconveniences for pts and providers
Lengthy appeals for denied svcs

Question 13

What are the cost control methods of MCOs?

Answer 13

Choice restriction
Gatekeeping
Case management
Dz management
Pharmaceutical management
Utilization review
Practice profiling

Question 14

Choice restriction in MCOs

Answer 14

Closed panel
Open access

Question 15

Definition of closed panel

Answer 15

In-network access
No access outside the panel

Question 16

Definition of open access

Answer 16

Out-of-network access
Outside option is allowed, but at a higher out-of-pocket cost

Question 17

Gatekeeping and MCOs

Answer 17

PCP as portal of entry
PCP delivers basic and routine care
PCP refers and coordinates when secondary care is needed
Gatekeeping achieves modest cost savings

Question 18

Case management and MCOs

Answer 18

Coordination of care for complex and potentially costly cases
A variety of svcs from multiple providers over an extended period
Coordination of an individual’s total HC in consultation with primary and secondary care providers by an experienced HC professional, such as an NP

Question 19

What does utilization management require?

Answer 19

An expert evaluation of what svcs are needed
A determination of how to provide svcs inexpensively without compromising quality
A review of the process of care and changes in the pt’s condition

Question 20

Dz management and MCOs

Answer 20

Pop-oriented strategy for chronic problems
Evidence-based tx guidelines
Focus on education, self-management training, monitoring of the dz process, and f/u to ensure compliance
To prevent or delay complications
Although cost savings are uncertain, better quality and dz control or achieved

Question 21

What are the 3 main strategies of pharmaceutical management in MCOs?

Answer 21

Drug formularies
Tiered cost sharing
Pharmacy benefits management companies (PBMs)

Question 22

Responsibilities of pharmacy benefits management companies

Answer 22

Extract discounts form pharmaceutical manufacturers
Handle drug utilization review

Question 23

What does utilization review ensure?

Answer 23

Appropriate levels of svcs are delivered
Care is cost-efficient
Subsequent care is planned

Question 24

What are the three main types of utilization review by the time when the review is undertaken?

Answer 24

Prospective UR
Concurrent UR and d/c planning
Retrospective UR

Question 25

Aspects of practice profiling

Answer 25

Evaluate provider-specific practice patterns
Profile monitoring
Compare to a norm
Feedback to change behavior
Goal: improve quality and efficiency
Somewhat controversial