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Managed Health Care Structure

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Dr. Karlene Richardson

on 27 May 2016

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Transcript of Managed Health Care Structure

Managed Care - From Start to Finish
Dr. Karlene Richardson

Elements of the Management Control and Governance Structure
Reimbursement and Risks

Prospective Payment System

The Origins of Managed Care
What led to its development?
primary-care orientation
utilization management

Common Myths & Assertions about Health Plans

What are common myths and assertions about health plans?
Physician Networks in
Managed Health Care
Basic elements in credentialing must include:

hospital privileges
malpractice history
medical license
continuing medical education (CME

In this class we learn how we all got here to this
point in history where we are . . . regarding the
insurance we have and the 47 million uninsured,
and capitation, prospective payment system,
and the list goes on and on . . . so in a
nutshell, welcome!
Integral Components of
Managed Care
Hospitals, Facilities, & Ancillary Services
Incentives in
Managed Health Care:
Managed Care is best describes as a broad and constantly changing array of health plans that attempt to manage both cost and quality of care

There are two basic ways to compensate
physicians in an IPA model HMO:
- Fee For Service

- Capitation
Physician sees patients
Physician bills insurance company for services provided
Physician gets paid no questions asked
The board of director has the
final responsibility for all the
aspects of an HMO
Providers in Managed Care Organizations
- Physicians

- Nurses
- Specialists
- Physician Assistants
- Nurse Practitioners
- Certified Medical Assistants
Known as physician extenders
May also serve as the medical director who has the responsibility of recruiting provider relation staff, oversight of utilization management and quality management
The function of the provider-relations staff is to:
communicate with physician panels (PCP and specialist)
communicate with office staff
update the network on changes within the plans' operation
elicit feedback regarding products and services

There are two types of prospective payment systems:

- Inpatient prospective payment system

- Outpatient prospective payment system
* Capitation
Reimbursement adjustments tied to performance
Bonus payments from plan funds
Bonus payments from employers

Common measures subject to P4P programs include: clinical measures patient safety, patient satisfaction use of information technology

Carved outs within a capitation contract can be defined as services billable
outside of a capitation payment
When selecting a hospital during the network-development phase an MCO considers the occupancy rate, costs and scope of service,
Common areas of clinical focus subject to hospital P4P programs include:
community acquired pneumonia
congestive heart failure
acute myocardial infarction

The hospitals reimbursement that contains no elements of risk sharing by the hospital is fee for service
After completing this module, student will be able to:
- Describe the different types of managed care [HMO, PPO, EPO, POS, IPA](Blooms Level 1)
- Compare managed care organizations [HMO, PPO, EPO, POS, IPA] (Blooms Level 2)
- Map the different types of managed care to the type of members, providers, network, etc. (Blooms Level 3)
- Explain managed care (Blooms Level 4)
- Justify the implementation of managed care as a cost containment strategy (Blooms Level 5)

After completing this homework students will be able to describe at least three types of cost containment strategies.
Describe at least three types of cost containment strategies.
Provide an example for each explaining
when each would be required.
Little Red Riding Hood (Handout)

Full transcript