Health Maintenance Organizations Flashcards
(20 cards)
MANAGED CARE
⚫ Describes a variety of techniques intended to ____________ of providing health benefits and __________________ (“managed care techniques”).
reduce the cost
improve the quality of care
GOALS OF MANAGED CARE
Managed care aims to ensure that:
⚫ Providers deliver _________ care in an environment that manages or _______________
⚫ Health care delivery services are relevant, in response to patients’ medical needs
⚫ Care is rendered by the most appropriate provider in an appropriate and less restrictive setting
high-quality
controls costs
⚫
PRINCIPLES GOVERNING
DELIVERY OF MANAGED CARE
⚫ Selective ________ contracting
⚫ ___________ management
⚫ Negotiated ________
⚫ ____________ management
⚫ Selective provider contracting
⚫ Utilization management
⚫ Negotiated payment
⚫ Quality management
TYPES OF MANAGED CARE
ORGANIZATIONS
⚫ ___________________ Organization-offer ________ health care coverage
⚫ ___________________ Organizations-similar to HMOs, but care is paid for when _____________ rather than ________________
Health Maintenance ;prepaid
Preferred Provider
it is received
in advance
A health maintenance organization (HMO) is a type of ____________ organization that provides health care coverage through hospitals, doctors,
and other providers with which the HMO has ________________.
managed care
a contract.
HMO offer __________ medical service in which members pay a ________ or ________ fee for all health care, including hospitalization.
⚫
prepaid ; monthly
yearly
The term “health maintenance organization” was coined by a health policy analyst, Dr. Paul Ellwood,
in the early 1970s.
Okay
CHARACTERISTICS OF HMOs (II)
⚫ HMOs often shift some financial risk to providers through a system called ‘____________ ’, where certain
providers receive a __________ per ________ per month and in return provide certain services for free.
⚫ The provider does not have the incentive to provide __________ care, as they will not receive any additional payment for the care.
⚫ This may however encourage the HMO to provide only the minimal contractually obligated healthcare,
in order to maximize profits. To counterbalance this trend some plans offer a bonus to providers whose
care meets a predetermined level of quality.
capitation’ ; fixed payment
member ; unnecessary
CHARACTERISTICS OF HMOs
⚫ HMOs contract with health care providers to deliver services to their members.
⚫ Care is provided to each member of the plan for a fixed amount.
⚫ An employer may contract with an HMO to provide care for its employees and pays this fixed charge.
⚫ Some HMOs also charge individuals a small ____________ for each visit
co-payment
CHARACTERISTICS OF HMOs (III)
⚫ A health plan is a set of defined health care benefits as offered to the _________ at a _________ payable as
agreed by the parties.
⚫ Doctor and patient are still decision makers, but their decisions are controlled by the managed care
____________.
⚫ The Primary Care Physician (PCP) is a doctor within the HMO network who acts as a “____________” to medical services, and authorizes referrals to
specialists or other doctors if deemed necessary.
enrollee ; premium
contract.
“gatekeeper”
COSTS ASSOCIATED WITH AN
HMO
⚫ The premium is a _______ amount paid to the _______ for accessing coverage.
⚫ The ___________ is any amount paid each time on receipt of covered medical services, or for certain services received, e.g. drugs outside of list, referrals – helps limit unnecessary use of services
⚫ A _________ is the amount a member must pay out of pocket before the HMO makes any payments for covered health services.
monthly ; HMO
co-payment
deductible
COST-CONTROL MECHANISMS
⚫ Primary care __________ – helps HMO to track and regulate costs
⚫ Use of ______________/__________ for routine care
⚫___________ of health care services that are not deemed necessary
⚫ Emphasis on ___________
⚫ Use of drug lists/___________
⚫ Reduction in freedom of choice of the member
physician
physician assistantnurse for routine
Exclusion ; prevention
formularies
HMO: PAYMENT MECHANISMS
⚫ Per-capita payment – the healthcare provider is paid a fixed amount per ___________ (through the HMO) rather
than for each visit or by type of service.
This is the method usually adopted at primary care level.
At secondary and tertiary level care, other forms of payment may be adopted:
⚫ Per case payment – this pays based on the ___________________
⚫ Diagnostic related groupings – similar conditions are grouped together and the same amount is paid for
any of them
⚫ ________ budgeting – bulk money is given to the provider for enrollees, with a free hand given to
provider in spending
person (
type of case seen
Global
A Health Maintenance Organization is a
private or public incorporated company
registered by the ___________________ solely to manage the provision of
health care services through Healthcare
Providers accredited by the Scheme
National Health Insurance Scheme
FUNCTIONS OF HMOs
The functions of HMOs shall include the following:
⚫ The _________ of contributions from registered employers and employees;
⚫ The collection of contributions from voluntary contributors;
⚫ Payment by __________ to Primary Providers and __________, per __________ , case payment to Secondary and Tertiary Providers;
⚫ Rendering to the Scheme monthly __________ on its activities within 30 days of the following month;
collection : capitation
fee-for- service, per diem, case
returns
⚫ Health Care Delivery System and
Administration
⚫ The HMOs shall develop a health care organizational structure which shall ensure that:
⚫ There is a well-developed and utilised ‘Primary Health Care
Provider’ (PHCP) System;
⚫ The PHCP shall be the first port of call for every contributor;
⚫ The PHCP may refer the contributor to a hospital or for specialist care where necessary; and
⚫ The hospital and specialist may refer the contributor or his dependant for defined limited rehabilitative care.
Health Care Delivery System and
Administration
⚫ The HMOs shall develop a health care
organizational structure which shall ensure that:
⚫ There is a well-developed and utilised ‘Primary Health Care
Provider’ (PHCP) System;
⚫ The PHCP shall be the first port of call for every
contributor;
⚫ The PHCP may refer the contributor to a hospital or for
specialist care where necessary; and
⚫ The hospital and specialist may refer the contributor or his
dependant for defined limited rehabilitative care.
FUNCTIONS OF HMOs (II)
⚫ Contracting with Health Care Providers accredited by the Scheme for the purpose of rendering health
care services;
⚫ Ensuring that contributions are kept in the Scheme’s accredited banks;
⚫ Establishing a quality assurance system for the provision of quality health care by Health Care
Providers;
⚫ Rendering accounts to the NHIS as required;
⚫ Marketing in accordance to NHIS Guidelines;
⚫ Carrying out such functions as are contained in the
NHIS Act and the Guidelines.
QUALITY ASSURANCE
To promote this, HMOs shall:
⚫ Establish _________________ at Provider facilities;
⚫ Undertake __________ monitoring and evaluation of Health Care Providers;
⚫ Organise regular ————- for Health Care Providers; and
⚫ Provide monthly statistical returns on Providers, i.e. rate of attendance, investigations, admissions, and
disease patterns.
complaints boxes
periodic monitoring
seminars
Merits:
⚫ _____ out of pocket payments – increased affordability
⚫ Focus on ________ care
⚫ ___________ Discourages unnecessary use of health services bymembers
Low
Preventative
Demerits:
⚫ Care is usually restricted to providers within the HMO network
⚫ _________ if there is delay in referral by PCP
⚫ Quality may be
compromised for the
sake of profit-making if
not well monitored
