5 - Managed Care Flashcards Preview

PUSHES > 5 - Managed Care > Flashcards

Flashcards in 5 - Managed Care Deck (18)
Loading flashcards...
1

Managed Care

COMBINES the functions of:

Health Insurance + Financing + Actual delivery of care

involves risk sharing of
delivery health services + deined network of providers

influences utilization + cost of services and measures the QUALITY OF PERFORMANCE

2

How does MANAGED CARE control
Costs + Service Utilization?

GATEKEEPING
Responsible for the admin of a patients treatment

CARE MANAGEMENT
Care coordination:
ensure EVERY PERSON served by the system has a single approved care / service plan that is coordinated within prescribed parameters

UTILIZATION REVIEW
Process to review decisions by providers on how much & what type of care to provice

3

Managed Care 3 Principles

Managing the care of the patients

using a SELECT GROUP of health care providers

placing PROVIDERS @ Risk financially

4

Major Types of 

MANAGED CARE ORGANIZATIONS

MCOs

HMOs = Health Maintenance Organizations

 

PPOs = Preferred Provider Organizations

 

POS Plans = Point of Service Plans

 

5

HMOs

type of managed care plan

Health Maintenence Organizations

Integrates financing + delivery of comprehensive healthcare services to members

Pre-determined pay / fixed premiumregardless of utilization

PCPs = GATEKEEPERS

4 Major Types of HMOs
Staff / Group > Network > IPA
models

6

Staff Model HMO

HMO employs ITS OWN PHYSICIANS + HCP's

Staff work in clinical facilities usually owned by the HMO

Services are provided EXCLUSIVELY to HMO plan enrolees

Centralized locations:
primary care / pharmacy / lab testing

Closed-Panel Model
there are some exceptions, like ambulence fees or out of state emergencies 

7

GROUP Model HMO

Contracts with a LARGE MULTI-SPECIALTY physician group to provide near exclusive care to HMO enrolees

Physicians are employed by the group practicenot the HMO

HMO reimburses on capitated bases

8

NETWORK Model HMO

HMO contracts with MULTIPLE Physican GROUPS to provide services to HMO members

non-exclusive contracts are made by the HMO with large medical groups in the network

HMO enrolees comprise a small part of any one  network physician's group's practices

9

IPA MODEL HMO

Individual Practice Associaition

(Independent)

IPA plan wherby physicians in solo private practice or small medical groups can join the IPA

IPA = LEGAL ENTITY, that functions as a intermediate organization representing INDIVIDUAL physicians / small groups

 

10

PPOs

Preferred Provider Organizations

Insurers contract with a panel of Participating Providers tohat provice services to enrollees:

Discounted Fee-For-Service Reimbursement

 

EPOs = Exclusive Provider Organization
form of PPO in which NO coverage provided outside the provider network

11

Point-Of-Service 

PLAN

 

 

HMO + PPO HYBRID

allows the covered person to CHOOSE / RECIEVE a serice from a participating or nonparticipting provider

 Must choose IN-NETWORK PCP

 

do NOT consfuse with POS SYSTEM, an electronic claims submission system used in pharmacy networks

12

HMOs = Health Maintenance Organizations

 

PPOs = Preferred Provider Organizations

 

POS Plans = Point of Service Plans

13

Pharmacy-related ISSUES

under Managed Care Environments

Prescription drug sales covered under managed care and subject to direct + indirect cost controls such as:
formularies / discounted fees / volume discoutnt / rebates / drug switching & generics

Need to manage the pharmacy benefit 

 

14

PBMs

Pharmacy Benefit Managers
assume admin functions in managing pharmacy benefit and containing costs for health plans

Promote optimal patient outcomes by:
establishing guidelines for safety/efficacy/quality/cost

MIDDLEMEN or intermediates between customers 

RX coverage / pharmacies / manufacturers / 3rd party payers

15

PBM Characteristics

THIRD PARTY ADMINISTRATOR
Pharmacy Benefit Manager

Administer drug benefit coverage of health plans on behalf of plan sponsers = gvmt / insurance / MCOs / rx drug plans

SEEK LOWEST COST from manufacturers and discounted prices from pharmacies

Similar to managed care, have a provicer network

 

16

PBM

Services + Strategies + Tools

Claims Processing for RX adjucation

POS SYSTEMS

Prior Authorization + Step Therapy

Clinical Management
DUR / Disease management

17

PBM report number of

COVERED LIVES

# of people enrolled including POLICY HOLDER + DEPENDENTS

can overlap among Companies

PBM may also report market share by RX value / revenue

28% CVS Caremark

28% Express Scripts

19% OptumRx

18

PBM Controversies

Contract with Community vs Mail Order vs Chain

limited for INDEPENDENT community pharmacies

large pharmacy chains have more LEVERAGE

revenue streams are NOT transparent, savings and rebates are QUESTIONABLE

market share concentration, small number (3) of the PBM's control MOST OF THE MARKET