Managed care lecture, part 3 Flashcards
Goals of organizational integration with managed care
Achieve economies of operation
Diversify existing ops by offering new svcs
Gain market share
Gain leverage with health plans
Integration strategies in managed care
Outright ownership: acquisition, merger
Joining hands with another org in the ownership of an entity: joint ventures
Having a stake in an org without owning it
Service strategies in managed care
Horizonal integration
Vertical integration
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 the basic forms of integration?
Management svc orgs (MSOs)
Physician-hospital orgs (PHOs)
Provider-sponsored orgs (PSOs)
Management svcs orgs
Supply management expertise, admin tools, and information tech to physician grp practices
Mainly used by small grps that cannot employ full-time managers
Physician-hospital orgs
An alliance between a hospital and physicians
A large PHO may contract directly with employers
Recent trend is for physicians to become hospital employees
Provider-sponsored orgs
A risk bearing entity (incorporation of insurance function) that competes with MCOs
Directly contract with employers and public insurers
PSOs failed in large numbers bc of a lack of experience with the insurance functions
Why did MSOs, PHO, and PSOs fail to gain momentum?
Lack of experience
Misplaced admin controls
Misaligned financial incentives
Unfavorable economic trends
What are forms of highly integrated systems?
Integrated delivery systems (IDSs)
Accountable Care Orgs (ACOs)
Payer provider integration
Aspects of integrated delivery systems
Aka integrated delivery network
A network of orgs that provides or arranges to provide a coordinated continuum of svcs to a defined pop
Willing to be held clinically and fiscally accountable for the outcomes and health status of the pop serviced
Example: Health Alliance Plan, Kaiser Foundation Health Plan
Managed care promoted the formation of IDSs
-Cost effective for MCOs to contract with a full service provider
-Preference by MCOs to seek cost-efficient providers who will take responsibility for quality
-Providers strengthened their bargaining power with MCOs and protected their autonomy
Accountable Care Orgs
Integrated grp of providers who take responsibility for delivering svcs to a defined pop
Take responsibility for improving health status, cost-efficient care, and satisfaction with care
Use mechanisms used by MCOs and IDSs to improve cost, quality, and pop health
ACO and the ACA
Medicare, authorized to develop payment methods for ACOs
Shared savings program: pay additional moneys to ACOs that achieve targeted cost savings while meeting quality standards
ACO and anti-trust
ACOs may be able to use their market power to inhibit competition by monopolizing pt referrals within the ACO
ACO’s size and geographic reach could be limited by antitrust laws, thus increasing competition
ACOs may find it difficult to achieve economies and care coordination, restrained by antitrust laws
