Flashcards in Managed Care Deck (36)
Indemnity (FFS) plans:
Use FFS payment model
Most expensive plans (premiums) for employers
Most insurers used a deductible
Most insurers used co-insurance
Type of payments:
Staff model HMO
Preferred Provider Organizations
Still had deductible & co-insurance
How is a PPO different from indemnity?
Restricted network (provider panel)
Co-insurance tied to allowable, not billed amount
Lower premiums than indemnity plans
Introduced Utilization Review (UR)
What model is used in a PPO?
Discounted Fee-For-Service (DFFS) as primary payment model
Secure a 20-50+% discount from providers
Goal of PPO plan:
pass along that 20-50% reduction to employers via lower premiums
Why didn't PPO plans work to pass reduction to employers?
Providers increased their prices
Providers saw more patients (increased demand)
Providers did more procedures (increased volume)
Old PPO model:
PPO paid 80-90% of the discounted rate after deductible was met
Patient paid 10-20% of what provider billed
PPO model now:
Copay (if applicable)
Co-insurance based on the allowable
PPO pays what is left to meet allowable after deductible is met
Decisions made based on restrospective review of documentation
To pay or not to pay
Who performs UR?
Not many PTs perform UR
How is HMO different from PPO
Smaller, more restricted, provider network than PPOs
Gatekeeper role for primary care physicians
Capitation for primary care physicians
Copays by patients BEFORE services
Pre-authorization by insurer and/or PCP for non-PCP services
Transfer of risk to providers, primarily PCPs
Who act as gatekeepers in a HMO?
How are PCPs paid in a HMO?
capitated rate on a monthly basis that is not tied to how many services are provided
What does a copay serve as?
A copay serves as a disincentive for the patient to receive healthcare services since they have to pay it up front versus 2-4 months after the service is provided
part of PMPM payment not given to PCP depending on goals
Withholds are returned to the PCP(s) only if those goals are met.
If goals are NOT met, then HMO keeps the withhold money
Who are HMOs popular with?
Why would employers like HMOs?
reduced premium growth
Why would insurers like HMOs?
reduced growth in healthcare expenditures
Why do providers dislike HMOs?
Made the providers the “bad guy”
Created perverse incentives with capitation
Why would consumers like HMOs?
low premium and OOP expenses
Why would consumers dislike HMOs?
they restricted/denied access to specialists
Staff model HMO:
Insurance company owns all entities from the insurer to the providers
Provides the most control over healthcare delivery
Lowest premiums of the HMO models
Group model HMO:
HMO contracts with one large multi-specialty physician group for all of their patients
Physicians do not work for the HMO
Can see patients from other insurers
Premiums higher than staff model
Which is the first model to reduce health care spending?
HMO contracts with numerous physician providers
Physicians do not work for the HMO
Physicians can see patients from other insurers
Premiums higher than group model
Independent Practitioner Association (IPA)
Physician practices contract with IPA who then contracts with HMO
Physicians not limited to IPA/HMO patients
Introduces middle man (IPA) that wants cut of premiums
Premiums higher than network HMO
Point of Service
Allows patients to seek care outside of the HMO physician/hospital network
However, patient’s pay higher co-pays and co-insurance for going out of network