Study guide for the final, part 9 Flashcards
Definition of closed panel
In-network access
No access outside the panel
Definition of open access
Out-of-network access
Outside option is allowed, but at a higher out-of-pocket cost
Case management and MCOs
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
What does utilization review ensure?
Appropriate levels of svcs are delivered
Care is cost-efficient
Subsequent care is planned
What are the three main types of utilization review by the time when the review is undertaken?
Prospective UR
Concurrent UR and d/c planning
Retrospective UR
Aspects of practice profiling
Evaluate provider-specific practice patterns
Profile monitoring
Compare to a norm
Feedback to change behavior
Goal: improve quality and efficiency
Somewhat controversial
Aspects of HMOs
Both medical care for illness and preventive care
PCP as gatekeeper
Capitation
In-network access (except hybrid and triple-option plans)
Carve outs for special svcs
Required to comply with standards of quality
Aspects of PPOs
Contracts with a grp of physicians and hospitals
Open-panel option
Discounted fee arrangement with providers (no direct risk sharing)
Fewer restrictions to the care seeking behaviors: no gatekeeping and other controls
What are the models of HMOs?
Staff
Group
Network
Independent practice association (IPA)
Staff model
Employ physicians on salary
Contracts for only uncommon specialties and hospital svcs
Greater control over practice patterns of physicians
Least popular model
Network model
Contract with more than one grp practice
A wider choice of physicians
Diluted utilization control
Managed care’s effect on quality
Overall, quality of care in MCO plans = traditional FFS
No evidence of skimping on care bc of capitation
Lower quality in for-profit plans vs non-profit plans
Enrollees of Medicare Advantage have a higher likelihood of rehopsitalization compared to those in original Medicare
Horizontal integration
Extends core product or svc
To control the geographic distribution of a certain type of HC svc
Not for diversification
Vertical integration
Links svcs at different stages in the production process of HC (across a continuum of care)
A diversification strategy
What are preferred by most older people and more rapidly grown than institutional svcs?
Community-based svcs
