PUP 4931r Lecture Notes - Lecture 77: Managed Care, Health Affairs, Medical Record
16 May 2018
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Many forms of Managed Care
Some not really MCOs
Many states used gatekeepers and called it Managed Care
PCCM: Primary care Case Management
FFS for PC services, plus small fee for monitoring patient use
Require primary care doc to sign off on request to see a specialist or get
equipment, etc.
Paid very little to doc, so many simply had their receptionist stamp the
request
Few states included disabled, or LTC, or special needs kids, mental health,
additions, etc.
Left the i FF“ or used are out – one MCO specializing in a carve out
2006 Florida introduced MCO Demonstration Pilot in 5 counties
Then soon expanded statewide.
Boldly, included almost all groups, and eventually did cover all groups
Key Features of MCO
Integration of financing, delivery
Facilitates control over enrollment, payment rates, scope of services, referrals,
providers participating, payment rates.
Endeavor to save money by
Selecting less costly patients
Profiling providers – avoiding those who prescribe too much or too
expensive care
Form networks of providers covering all required services and require
patients to stay in-network or pay out of pocket or large co-pay
Demand volume discount from network providers
Aept loer prie for guaratee of all MCO’s patiets
Some Potential Benefits
Access:
If you are in an MCO, you have access to medially needed providers
Reduces your transaction (search) costs
Guaratees you’ll e aepted by network providers
Usually modest co-payments
find more resources at oneclass.com
find more resources at oneclass.com
Document Summary
Many states used gatekeepers and called it managed care. Ffs for pc services, plus small fee for monitoring patient use. Require primary care doc to sign off on request to see a specialist or get equipment, etc. Paid very little to doc, so many simply had their receptionist stamp the request. Few states included disabled, or ltc, or special needs kids, mental health, additions, etc. Left the(cid:373) i(cid:374) ff or used (cid:862)(cid:272)ar(cid:448)e out(cid:863) one mco specializing in a carve out. 2006 florida introduced mco demonstration pilot in 5 counties. Boldly, included almost all groups, and eventually did cover all groups. Facilitates control over enrollment, payment rates, scope of services, referrals, providers participating, payment rates. Profiling providers avoiding those who prescribe too much or too expensive care. Form networks of providers covering all required services and require patients to stay in-network or pay out of pocket or large co-pay. A(cid:272)(cid:272)ept lo(cid:449)er pri(cid:272)e for guara(cid:374)tee of all mco"s patie(cid:374)ts.
