Managed care
-a system of health care delivery that tries to control the cost of health care services while regulating access to those services and maintaining or improving their quality
purchasers, members, healthcare providers, MCOs
Who are the 4 key players in managed care?
Purchasers
-public or private entities or organizations that buy healthcare coverage for workers, dependents, retirees, or other beneficiaries.
employers, medicare, medicaid
Generally, purchasers are one of three large groups:
Members
-an individual who is enrolled or covered by a managed care plan
-those who receive individual health care services from provides
Healthcare providers
- a physician, other health care provider, or health care facility that delivers healthcare services to individuals in a managed care plan
MCOs
-entities that offer managed care plans
-can be owned by hospitals, physican groups, integrated delivery systems
-may offer several plans to one employer
Population-based health management
-MCOs identify prevalent risk factors and incidence of diseases among the membership and then develop target programs to best care for the membership.
Utilization management
-the process of assessing the necessity, appropriateness, and efficacy of health care before, during, or after services are rendered.
a
Which utilization control method involves pre-certification, prior authorization, and second opinions?
a. Prospective UM
b. Concurrent UM
c. Retrospective UM
b
Which utilization control method involves reviewing hospital cases, discharge planning, and case management?
a. Prospective UM
b. Concurrent UM
c. Retrospective UM
c
Which utilization control method involves the denial of claims that may involve an appeal process?
a. Prospective UM
b. Concurrent UM
c. Retrospective UM
NCQA (national committee for quality assurance)
- a not-for profit organization dedicated to assessing and reporting on quality and performance of health care plans
accreditation, report cards, performance measurement
What are the three activities NCQA participates in to assess on quality and performance of health care plans?
report cards
-help employers, government, and consumers compare the performances of various plans for the purposes of selecting a plan
HEDIS
-a set of standardized performance measures designed to ensure that purchasers and consumers have the information they need to reliably compare the performance of managed health care plans
PBM
-a company that adjudicates prescription drug claims and manages prescription drug coverage for a managed care organization by containing costs and influencing the quality of services provided.
creating pharmacy networks, offering mail order, negotiating reimbursement, claims adjudication, formularies, DUR
What are some of the roles of Pharmacy Benefit Managers (PBMs)?
create a network
PBMs contract with community pharmacies to __________ of pharmacies from which patients can receive prescriptions
Mail order
-used as a result of large prescription volume
-able to negotiate discounts on product costs in efforts to reduce dispensing costs
formularies
-a list of medications compiled by a PBM that contain either those drugs approved for reimbursement
closed formulary
-drugs not on the formulary are not covered by the health plan
incented formulary
patients pays lower copays for preferred drugs
DUR
-retrospective review of physician prescribing, pharmacists dispensing, and patient use of drugs
-primary goal to ensure drugs are used appropriately, safely, and effectively
medications that are used to treat chronic conditions
Mail order is usually used for what kind of medications?
risk bearing, physician type, relationship exclusivity, out-of-network coverage
What are the 4 characteristics used to differentiate managed care plans?