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