MANAGED CARE

MANAGED CARE PLANS
COMBINE THE DELIVERY OF
HEALTH CARE WITH THE
FINANCING OF THAT CARE.

IN A MANAGED CARE PLAN, SUCH
AS A HEALTH MAINTENANCE
ORGANIZATION (HMO) OR A
PREFERRED PROVIDER
ORGANIZATION (PPO), YOU
RECEIVE YOUR HEALTH CARE FROM
A GROUP OF PHYSICIANS,
HOSPITALS, AND OTHER SERVICE
PROVIDERS SELECTED BY THE
PLAN.

IN EXCHANGE, YOU PAY A SET
MONTHLY FEE FOR THE
SERVICES YOU RECEIVE.

Goals of Managed Health Care
Plans
Provide high quality care in an
environment that controls cost
Care is medically necessary and
appropriate
Goals (Continued)
Care is rendered by the most
appropriate provider
Care is rendered in the most
appropriate, least-restrictive
environment
TYPES OF MANAGED CARE
PLANS

HEALTH MAINTENANCE
ORGANIZATION
GROUP AND STAFF MODEL
HMO’S ARE THE MOST
RESTRICTIVE AND PROVIDE
FEWER CHOICES OF
PROVIDERS TO
CONSUMERS.
ON THE OTHER HAND, THIS
MODEL OFTEN OFFERS ONESTOP CARE WHICH MEANS
THAT ALL YOUR DOCTORS,
AS WELL AS LABORATORY
AND X-RAY SERVICES ARE
X-RAY SERVICES ARE
LOCATED IN ONE MEDICAL
FACILITY.
IN A GROUP OR STAFF
HMO, YOU MUST CHOOSE A
PRIMARY PHYSICIAN. IF
YOU DON’T, THEY WILL
CHOOSE ONE FOR YOU.
– INDIVIDUAL PRACTICE
ASSOCIATONS (IPA’S)

INDIVIDUAL PRACTICE
ASSOCIATIONS (IPA’S) ARE A
LESS RESTRICTIVE FORM OF
HMO THAN THE GROUP OR
STAFF MODEL.
INDIVIDUAL PHYSICIANS
PRACTICING IN THEIR
OWN OFFICES ARE UNDER
CONTRACT TO A
SEPARATE GROUP,
CALLED AN “IPA” THAT,
IN TURN, CONTRACTS
WITH AN HMO.
THE HMO PROVIDES YOU
WITH A LIST OF
PARTICIPATING
PHYSICIANS FROM WHICH
YOU MAY CHOOSE YOUR
PRIMARY CARE DOCTOR.
VISITS TAKE PLACE IN THE
DOCTOR’S OFFICE. IF YOU
REQUIRE SPECIALITY CARE,
YOUR PRIMARY CARE
DOCTOR REFERS YOU TO A
PARTICIPATING
SPECIALIST.

BY FAR THE LARGEST NUMBER
OF HMO MEMBERS ARE
ENROLLED IN THE IPA MODEL.
PHYSICIANS MAY BELONG
TO MORE THAN ONE HMO
AND ALSO MAY CONTINUE
TO SEE FEE-FOR-SERVICE
PATIENTS IN THEIR OFFICE.

POINT OF SERVICE (POS)
POINT OF SERVICE (POS)
PLANS PERMIT MEMBERS
GREATER CHOICE AND
FLEXIBILITY BY ALLOWING
YOU THE OPTION OF GOING
“OUT OF PLAN” TO USE
NON-HMO PROVIDERS.

IF YOU GO “OUT OF PLAN,” YOU
MUST PAY MORE, TYPICALLY
IN THE FORM OF HIGH
COINSURANCE AND
DEDUCTIONS.
– PREFERRED PROVIDER
ORGANIZATION (PPO)
PREFERRED PROVIDER
ORGANIZATION (PPO) ARE
NETWORKS OF DOCTORS AND
HOSPITALS THAT HAVE
AGREED TO GIVE THE
SPONSORING ORGANIZATION
DISCOUNTS ON THEIR USUAL
RATES. (USUALLY AN
EMPLOYER OR INSURANCE
COMPANY).
SOME PPO’S USE PRIMARY
CARE PHYSICIANS AS
GATEKEEPERS.

IN OTHERS, YOU MAY CHOOSE
YOUR OWN DOCTORS AND
VISIT SPECIALISTS WITHOUT
PERMISSION FROM A
GATEKEEPER.
PPO’S OFFER YOU THE
GREATEST FREEDOM AMONG
MANAGED CARE PLANS IN
SELECTING HEALTH CARE
PROVIDERS BUT PPO
PREMIUMS ARE USUALLY
SOMEWHAT HIGHER THAN HMO
PREMIUMS AND THERE IS LESS
COORDINATION OF CARE.

DEFINED CARE

Employer sponsored Defined
Contribution Health plans.

Provides an allowance that
empowers consumers to purchase
and select from a wide menu of
benefit options
•MANAGED CARE VS.
TRADITIONAL HEALTH
INSURANCE
•RECEIVING CARE

GATEKEEPERS
UNDER FEE-FOR-SERVICE
INSURANCE OR TRADITIONAL
HEALTH INSURANCE, YOU CAN
CHOOSE ANY LICENSED
PHYSICIAN TO BE YOUR
PERSONAL DOCTOR AND YOU
CAN THE SERVICES OF ANY
HEALTH CARE FACILITY OR
SERVICES.
UNDER MANAGED CARE,
MEMBERS RECEIVE CARE
THAT IS PROVIDED
DIRECTLY OR AUTHORIZED
BY THE MANAGED CARE
PLAN.

THE PRIMARY CARE DOCTOR
YOU CHOOSE BECOMES YOUR
PERSONAL PHYSICIAN AND
COORDINATES YOUR CARE.

THE DOCTOR ACTS A
“GATEKEEPER,” TREATING YOU
DIRECTLY OR AUTHORIZING
YOU TO HAVE TESTS, SEE A
SPECIALIST, OR ENTER A
HOSPITAL.

THE “GATEKEEPER”
ARRANGEMENT IS DESIGNED
TO PROVIDE THE NECESSARY
CARE AT THE LOWEST COST
AND TO AVOID GIVING
UNNECESSARY CARE.
– QUALITY REVIEW

UNDER TRADITIONAL HEALTH
INSURANCE PLANS, DOCTORS
PRACTICE INDEPENDENTLY WITH
LITTLE OR NO ASSESSMENT OF
THEIR PERFORMANCE BY THEIR
PEERS OR GOVERNMENT
REGULATORS.

MANAGED CARE PLANS
USUALLY HAVE QUALITY
REVIEW PROCEDURES THAT
MAY INCLUDE INTERNAL AND
EXTERNAL QUALITY
ASSURANCE PROGRAMS.
PLANS “FEDERALLY
QUALIFIED” TO PROVIDE
HEALTH CARE TO
MEDICARE OR MEDICAID
ENROLLEES, UNDER LAW
MUST HAVE QUALITY
ASSURANCE PROGRAMS.
THE OVERALL
PERFORMANCE OF THE
PLAN IS MONITORED
THROUGH GOVERNMENT
OVERSIGHT, PATIENT
SATISFACTION SURVEYS,
DATA FROM GRIEVANCE
PROCEDURES, AND
INDEPENDENT REVIEWS.
–UTILIZATION REVIEW
MANAGED CARE PLANS
REVIEW THE MEDICAL CARE
PROVIDED BY YOUR
DOCTORS TO DETERMINE
WHETHER OR NOT IT IS
APPROPRIATE AND
NECESSARY.
WHEN HOSPITAL CARE IS
INDICATED, OTHER
FACTORS AND
SAFEGUARDS IN THE
UTILIZATION REVIEW
INCLUDE:
CARE IN ADVANCE.
WITHOUT IT, THE PLAN
MAY PREADMISSION
CERTIFICATION: APPROVAL
FOR NOT PAY FOR NONEMERGENCY SERVICES.
CONCURRENT REVIEW:
MANAGED CARE PLANS
MONITOR YOUR HOSPITAL
STAYS TO BE SURE THEY ARE
NO LONGER THAN ABSOLUTELY
NEEDED AND THAT ALL TESTS
AND PROCEDURES ORDERED
ARE MEDICALLY NECESSARY.
DISCHARGE PLANNING:
PLANS WANT TO KEEP
HOSPITAL STAYS TO THEIR
SHORTEST APPROPRIATE
LENGTH. IF NECESSARY,
THE PLAN WILL ARRANGE
POST-HOSPITAL CARE,
INCLUDING NURSING HOME
OR HOME HEALTH CARE.
CASE MANAGEMENT: CASE
PLANS ARE DEVELOPED
FOR COMPLICATED CASES
TO BE SURE CARE IS
COORDINATED AND
PROVIDED IN THE MOST
COST-EFFECTIVE MANNER.
SECOND SURGICAL OPINIONS:
PLANS MAY REQUIRE A
SECOND OPINION BEFORE
SCHEDULING ELECTIVE
SURGERY. THE SECOND
PHYSICIAN MAY BE ASKED TO
JUDGE THE NECESSITY OF THE
SURGERY AND ALSO TO
EXPRESS AN OPINION ON THE
MOST ECONOMICAL,
APPROPRIATE PLACE TO
PERFORM THE SURGERY.
–PAYING FOR CARE
FOR MOST PEOPLE WITH
TRADITIONAL HEALTH
INSURANCE, PREMIUMS
ARE ONLY ONE PART OF
THE COST. CONSUMERS
ALSO PAY DEDUCTIBLES,
COINSURANCE, AND THE
COST OF SERVICES THAT
ARE NOT COVERED.

WITH MANAGED CARE, OUT-OFPOCKET COSTS ARE
GENERALLY LOWER, AND
THERE IS FAR LESS
PAPERWORK FOR PLAN
MEMBERS TO CONTEND WITH.
–THE PROS AND CONS

HMO STAFF MODEL:
PROS: CENTRALIZED FACILITY
WHERE CARE IS PROVIDED AND
COORDINATED; LOW COPAYMENTS;
PREVENTATIVE CARE; NO CLAIM
FORMS.
CONS: MUST USE DOCTOR IN THE
HMO; PLAN MUST APPROVE
TREATMENT AND MAKE REFERRALS.

HMO INDIVIDUAL PRACTICE
ASSOCIATION:
PROS: PROVIDERS USE THEIR OWN
OFFICES; LOW COPAYMENTS;
PREVENTATIVE CARE; NO CLAIM
FORMS.
CONS: MUST USE DOCTORS IN
THE HMO; PLAN MUST APPROVE
TREATMENT AND MAKE
REFERRALS.

HMO POINT OF SERVICE:
PROS: MORE CHOICE OF PROVIDERS
OUTSIDE THE NETWORK; LOWER
COST WITHIN THE NETWORK;
PREVENTIVE CARE COVERED.
CONS: HIGHER COST OUTSIDE THE
NETWORK; OUT-OF-NETWORK
COVERAGE MAY BE LIMITED; PLAN
MUST SOMETIMES APPROVE
TREATMENT AND MAKE REFERRALS.

PREFERRED PROVIDER
ORGANIZATION (PPO):
PROS: CHOICE OF STAYING IN OR
GOING OUT OF THE NETWORK FOR
CARE. LOWER COST IF PROVIDERS
WITHIN NETWORK ARE USED.
CONS: HIGH COST OUTSIDE THE
NETWORK; ADDITIONAL PAPERWORK
TO SECURE APPROVAL FOR SOME
SERVICES; LIMITED COORDINATION

TRADITIONAL HEALTH
INSURANCE:
PROS: UNRESTRICTED CHOICE OF
PROVIDER.
CONS: USUALLY MORE EXPENSIVE;
LITTLE OR NO COORDINATION OF
CARE; PREVENTIVE CARE USUALLY
NOT COVERED; CLAIM FORMS TO
FILE.

KEY TERMS AND CONCEPTS
– MEMBERS:

IN MANAGED CARE EACH PATIENT
WITH INSURANCE COVERAGE
UNDER A HEALTH PLAN IS CALLED
A MEMBER. OTHER TERMS
INCLUDE ENROLLEES AND
COVERED LIVES.
PER MEMBER PER MONTH
IS A RELATIVE MEASURE,
THE RATIO, BY WHICH
MOST EXPENSE AND
REVENUE, AND MANY
UTILIZATION
COMPARISONS ARE MADE.

MEDICAL MANAGEMENT TERMS

QUALITY MANAGEMENT
INVOLVES ENSURING MEMBERS ARE
GETTING ACCESSIBLE AND
AVAILABLE CARE, DELIVERED
WITHIN COMMUNITY STANDARDS;
AND ENSURING A SYSTEM TO
IDENTIFY AND CORRECT PROBLEMS,
AND TO MONITOR ONGOING
PERFORMANCE.

UTILIZATION MANAGEMENT
INVOLVES COORDINATING HOW
MUCH OR HOW CARE IS GIVEN FOR
EACH PATIENT, AS WELL AS THE
LEVEL OF CARE. THE GOAL IS TO
ENSURE CARE IS DELIVERED COSTEFFECTIVELY, AT THE RIGHT LEVEL,
AND DOESN’T USE UNNECESSARY
RESOURCES.

OUTCOMES MANAGEMENT
DETERMINES THE CLINICAL
END-RESULTS ACCORDING TO
DEFINED VARIOUS CATEGORIES
AND THEN PROMOTE USE OF
THOSE CATEGORIES WHICH
YIELD IMPROVED OUTCOMES.

DEMAND MANAGEMENT
A PROGRAM ADMINISTERED BY
THE PROVIDER ORGANIZATION
TO MONITOR AND PROCESS
MANY TYPES OF INITIAL
MEMBER REQUESTS FOR
CLINICAL INFORMATION AND
SERVICES.

DISEASE MANAGEMENT
INVOLVES ASPECTS OF CASE AND
OUTCOMES MANAGEMENT, BUT
APPROACH FOCUSES ON SPECIFIC
DISEASES, LOOKING AT WHAT
CREATES THE COSTS, WHAT
TREATMENT PLAN WORKS,
EDUCATING PATIENTS AND
PROVIDERS, AND COORDINATING
CARE AT ALL LEVELS. HOSPITAL,
PHARMACY, PHYSICIAN, ETC.

SHARING FINANCIAL RISK

CAPITATION
CAPITATION MEANS PAY A FIX AMOUNT OF
MONEY PER PERSON (PER CAPITA).
CAPITATION PUTS A LID ON PAYMENTS PER
PERSON THAT OTHERWISE MIGHT CHANGE
UNDER A FEE-FOR-SERVICE SYSTEM.
PROVIDERS ARE AT FULL FINANCIAL RISK
FOR THE SERVICES CAPITATED. THE
PROVIDER IS PAID A FIX AMOUNT PER
MEMBER ENROLLED, REGARDLESS OF THE
NUMBER OF SERVICES DELIVERED TO THAT
MEMBER.

WHAT THE FUTURE HOLDS

RIGHT AROUND THE CORNER

Managed Care Backlash will
become a permanent fixture,
without producing radical
reform.


However, pharmaceutical costs
may surpass managed care
backlash in the number one
health care public “hot seat.”
PPO and Point of Service
enrollment gains will continue.

HMO’S will continue to soften
management techniques

Plan premium & provider costs
increases will continue

Provider clout over health plans
will continue to solidify.


Employers will grudgingly
accept price increases as long
as the labor market is tight.
Medicare HMOs won’t disappear
despite pundit’s warnings to the
contrary.



LONGER TERM..
When the economy diminishes,
more proactive changes will
occur.
Defined Care and consumerism
will become a major factor.


New medical technology
advancements will dictate future
medical management techniques.
Legislative reform will remain
incremental, not radical, unless
there is a devastating recession
where uninsured numbers swell.

End of lecture for Monday, October
17th, 2011, 6th Period

Questions?
MANAGED CARE
FACTS, TERMS, AND
DEFINITIONS

FACTS ABOUT MANAGED CARE



NUMBER OF HMOS IN THE UNITED STATES
= 574
NUMBER OF PPOS IN THE UNITED STATES =
1036
NUMBER OF AMERICANS IN HMOS = 79.3
MILLION



NUMBER OF AMERICANS IN PPOS = 89.1
MILLION
NUMBER OF AMERICANS IN ALL MANAGED
CARE PROGRAMS = 206 MILLION
PERCENTAGE OF INSURED EMPLOYEES IN
MANAGED CARE HEALTH PLANS = 66%



PERCENTAGE OF MEDICARE ENROLLEES IN
HMOS = 9%
PERCENTAGE OF MEDICAID ENROLLEES IN
HMOS = 19.4%
PERCENTAGEOF MDS WITH AT LEAST ONE
MANAGED CARE CONTRACT = 75%



PERCENTAGE OF MDS WITH AT LEAST ONE
HMO CONTRACT = 48%
PERCENTAGE OF HMOS THAT ARE FORPROFIT = 69%
PERCENTAGE OF HMOS THAT ARE NOT-FORPROFIT = 42.2 %

PERCENTAGE OF HMOS WITH LISTS OF
APPROVED PRESCRIPTION DRUGS – 100%

OrganizationManaged Care enrollment


WellPoint, Inc. 27,236,851
UnitedHealth Group, Inc. 21,684,629
Aetna, Inc. 14,172,723
Health Care Service Corporation 12,262,905
CIGNA Health care, Inc. 9,064,024
Kaiser Permanente 8,825,581
Humana, Inc. 7,699,106
Blue Cross Blue Shield of Michigan 4,937,591
Highmark, Inc. 4,739,178
HIP Health Plan of New York 4,285,194

Total (for US) 206,226,739









MANAGED CARE TERMS


AMBULATORY CARE
ALL TYPES OF HEALTH SERVICES
THAT ARE PROVIDED ON AN
OUTPATIENT BASIS, IN CONTRAST
TO SERVICES PROVIDED IN THE
HOME OR TO PERSONS WHO ARE
HOSPITAL INPATIENTS.


CASE MANAGEMENT
THE PROCESS BY WHICH ALL HEALTH
RELATED MATTERS OF A CASE ARE
MANAGED BY A PHYSICIAN OR NURSE OR
DESIGNATED HEALTH PROFESSIONAL.
PHYSICIAN CASE MANAGERS COORDINATE
DESIGNATED COMPONENTS OF HEALTH
CARE, SUCH AS APPROPRIATE REFERRAL TO
CONSULTANTS, SPECIALISTS, HOSPITALS,
ANCILLARY PROVIDERS AND SERVICES.

CASE MANAGEMENT IS INTENDED TO
ENSURE CONTINUITY OF SERVICES
AND ACCESSIBILITY TO OVERCOME
RIGIDITY, FRAGMENTED SERVICES,
AND THE MISUTILIZATION OF
FACILITIES AND RESOURCES.


COPAYMENT
A COST-SHARING ARRANGEMENT IN
WHICH A MEMBER PAYS A SPECIFIED
CHARGE FOR A SPECIFIED SERVICE.
THE MEMBER IS USUALLY
RESPONSIBLE FOR PAYMENT AT THE
TIME THE SERVICE IS RENDERED.


COST SHARING
A GENERAL SET OF FINANCING
ARRANGEMENTS IN WHICH A
COVERED MEMBER MUST PAY A
PORTION OF THE COSTS
ASSOCIATED WITH RECEIVING CARE,
E.G., CO-PAYMENT, COINSURANCE OR
DEDUCTIBLE.


DIAGNOSIS RELATED GROUPS (DRG)
A SYSTEM OF CLASSIFICATION FOR
INPATIENT HOSPITAL SERVICES BASED ON
DIAGNOSIS, AGE, SEX, AND PRESENCE OF
COMPLICATIONS. IT IS USED AS A MEANS
OF IDENTIFYING COSTS FOR PROVIDING
SERVICES ASSOCIATED WITH THE
DIAGNOSIS AND AS A MECHANISM TO
REIMBURSE HOSPITAL AND SELECTED
OTHER PROVIDERS FOR SERVICES
RENDERED.


FEE-FOR-SERVICE
A PAYMENT SYSTEM BY WHICH
DOCTORS, HOSPITALS AND OTHER
PROVIDERS ARE PAID A SPECIFIC
AMOUNT FOR EACH SERVICE
PERFORMED AS IT IS RENDERED AND
IDENTIFIED BYA CLAIM FOR
PAYMENT.


FORMULARY
A LIST OF SELECTED PHARMACEUTICALS
AND THEIR APPROPRIATE DOSAGES FELT TO
BE THE MOST USEFUL AND COST EFFECTIVE
FOR PATIENT CARE. IN SOME MANAGED
CARE PLANS, PROVIDERS ARE REQUIRED TO
PRESCRIBE FROM THE FORMULARY.


GROUP OR NETWORK HMO
A MANAGED CARE ORGANIZATION IN
WHICH THE MANAGED CARE
ORGANIZATION CONTRACTS WITH MORE
THAN ONE PHYSICIAN GROUP, AND MAY
CONTRACT WITH SINGLE AND MULTISPECIALITY GROUPS THAT WORK OUT OF
THEIR OWN OFFICE FACILITY. THE
NETWORK MAY OR MAY NOT PROVIDE CARE
EXCLUSIVELY FOR THE MANAGED CARE
ORGANIZATION’S MEMBERS.


CENTER FOR MEDICARE AND
MEDICAID
CMS IS THE FEDERAL AGENCY THAT
ADMINISTERS THEMEDICARE AND
MEDICAID PROGRAMS, AND WORKS
TO ASSURE THAT THE
BENEFICIARIES ENROLLED IN THESE
PROGRAMS HAVE ACCESS TO HIGH
QUALITY CARE.


INDEMNITY PLAN
A PLAN WHICH REIMBURSES PHYSICIANS
FOR SERVICES PERFORMED, OR
BENEFICIARIES FOR MEDICAL EXPENSES
INCURRED (RETROACTIVE PAYMENT). SUCH
PLANS ARE DIFFERENT FROM GROUP
HEALTH PLANS, WHICH RECEIVE A SPECIFIC
AMOUNT IN ADVANCE TO COVER ALL OR
CERTAIN HEALTH CARE SERVICES FOR A
SPECIFIC POPULATION (PROSPECTIVE
PAYMENT).


INDIVIDUAL PRACTICE ASOCIATION (IPA) MODEL
A MANAGED CARE ORGANIZATION THAT
CONTRACTS WITH INDIVIDUAL PRACTITIONERS
OR AN ASSOCIATION OR INDIVIDUAL PRACTICES
TO PROVIDE HEALTH CARE SERVICES IN RETURN
FOR A NEGOTIATED FEE. THE INDIVIDUAL
PRACTICE ASSOCIATION, IN TURN,
COMPENSATES ITS PHYSICIANS ON A PER
CAPITA, FEE SCHEDULE, OR OTHER AGREED-UPON
BASIS.


LOCK-IN
A CONTRACTUAL PROVISION BY WHICH
MEMBERS, EXCEPT IN CASES OF
UNFORESEEN OUT-OF-AREA URGENTLY
NEEDED CARE OR EMERGENCY CARE, ARE
REQUIRED TO RECEIVE ALL THEIR CARE
FROM THE MANAGED CARE PLAN’S NETWORK
OF HEALTH CARE PROVIDERS.


MANAGED CARE ORGANIZATION
AN ENTITY THAT INTEGRATES FINANCING
AND MANAGEMENT WITH THE DELIVERY OF
HEALTH CARE SERVICES TO AN ENROLLED
POPULATION. AN MCO PROVIDES, OFFERS,
OR ARRANGES COVERAGE OF DESIGNATED
HEALTH SERVICES NEEDED BY MEMBERS
FOR A FIXED, PREPAID AMOUNT.


MEDICALLY NECESSARY
SERVICES OR SUPPLIES WHICH MEET THE
FOLLOWING:
• THEY ARE APPROPRIATE AND
NECESSARY FOR THE SYMPTOMS,
DIAGNOSIS, OR TREATMENT OF THE
MEDICAL CONDITION;
• THEY ARE PROVIDED FOR THE
DIAGNOSIS OR DIRECT CARE AND
TREATMENT OF MEDICAL
CONDITIONS;
• THEY MEET THE STANDARDS OF GOOD
MEDICAL PRACTICE WITHIN THE
MEDICAL COMMUNITY OF THE SERVICE
AREA;
• THEY ARE NOT PRIMARILY FOR THE
CONVENIENCE OF THE PATIENT OR
PROVIDER;
• THEY ARE THE MOST APPROPRIATE
LEVEL OR SUPPLY OF SERVICE WHICH
CAN SAFELY BE PROVIDED.


MEDICARE MANAGED CARE
MEDICARE MANAGED CARE IS A HEALTH
CARE OPTION YOU CAN CHOOSE TO
RECEIVE YOUR MEDICARE BENEFITS.
MANAGED CARE PLANS HAVE CONTRACTS
WITH THE GOVERNMENT, SPECIFICALLY
THE HEALTH CARE FINANCING
ADMINISTRATION, TO PROVIDE YOUR
MEDICARE BENEFITS.


MEDICARE SUPPLEMENT INSURANCE
PRIVATE HEALTH INSURANCE THAT PAYS
CERTAIN COSTS NOT COVERED BY FEE-FORSERVICE MEDICARE, SUCH AS MEDICARE
COINSURANCE AND DEDUCTIBLES.


POINT-OF-SERVICE (POS) OPTION
A MEMBER’S OPTION TO CHOOSE TO
RECEIVE A SERVICE FROM OUTSIDE THE
PLAN’S NETWORK OF PROVIDERS FOR AN
ADDITIONAL FEE SET BY THE PLAN.
GENERALLY, THE LEVEL OF COVERAGE IS
REDUCED FOR SERVICES ASSOCIATED WITH
THE USE OF NON-PARTICIPATING
PROVIDERS.


PREFERRED PROVIDERS
PHYSICIANS, HOSPITALS, AND
OTHER HEALTH CARE PROVIDERS
WHO CONTRACT TO PROVIDE HEALTH
SERVICES TO PERSONS COVERED BY A
PARTICULAR HEALTH PLAN.


PREFERRED PROVIDER ORGANIZATION (PPO)
A HEALTH CARE DELIVERY SYSTEM THAT
CONTRACTS WITH PROVIDERS OF MEDICAL
CARE TO PROVIDE SERVICES AT
DISCOUNTED FEES TO MEMBERS. MEMBERS
MAY SEEK CARE FROM NON-PARTICIPATING
PROVIDERS BUT GENERALLY ARE
FINANCIALLY PENALIZED FOR DOING SO BY
THE LOSS OF THE DISCOUNT AND
SUBJECTION TO COPAYMENTS AND
DEDUCTIBLES.


PRIMARY CARE NETWORK (PCN)
A GROUP OF PRIMARY CARE
PHYSICIANS WHO SHARE THE RISK
OF PROVIDING CARE TO MEMBERS OF
A GIVEN HEALTH PLAN.


PRIMARY CARE PHYSICIANS (PCP)
THE PHYSICAN THAT SERVES AS THE
INITIAL CONTACT BETWEEN THE MEMBER
AND THE MEDICAL CARE SYSTEM. THE PCP
IS USUALLY A PHYSICIAN WHO IS TRAINED
IN ONE OF THE PRIMARY CARE
SPECIALITIES, AND WHO TREATS AND IS
RESPONSIBLE FOR COORDINATING THE
TREATMENT OF MEMBERS ASSIGNED TO
HIS OR HER PANEL.


PROVIDER
A HEALTH CARE PROVIDER OR
FACILITY THAT IS PART OF THE
MANAGED CARE PLAN’S NETWORK
USUALLY HAVING FORMAL
ARRANGEMENTS TO PROVIDE
SERVICES TO THE PLAN’S MEMBERS.


QUALITY ASSURANCE
A FORMAL METHODOLOGY AND SET OF
ACTIVITIES DESIGNED TO ASSESS THE
QUALITY OF SERVICES PROVIDED.
QUALITY ASSURANCE INCLUDES FORMAL
REVIEW OF CARE, PROBLEM
IDENTIFICATION, AND CORRECTIVE
ACTIONS TO REMEDY ANY DEFICIENCIES
AND EVALUATION OF ACTIONS TAKEN.


STAFF MODEL
THIS MANAGED CARE ORGANIZATION
MODEL EMPLOYS PHYSICIANS TO PROVIDE
HEALTH CARE TO ITS MEMBERS. ALL
PREMIUMS AND OTHER REVENUES ACCRUE
TO THE MANAGED CARE ORGANIZATION,
WHICH COMPENSATES PHYSICIANS BY
SALARY.


End of lecture for 6th Period,
October 19th - 2011
Questions?