Summary of Lectures (Part 2)

71 views3 pages
ECMC34 ± March 16
Workers compensation insurance ± costs are rising, but not in the normal health care
- Costs are higher because someone is paying for it
- Constraints on physicians on what treatment they can provide
Managed Care - A system in which physician practice is managed in order to address high health
care costs
- Managed Care Organization (MCO)
- Health Management Organization (HMO)
- Fee for Service (FFS)
- Preferred provider organization (PPO)
- Point of service (POS)
Managed care reduces overconsumption of health care by imposing cost control incentives (on
both physician + patient)
- Set up a network, collection of physicians, hospitals clinics, home care to a defined
population in an area
- Network is clinically (quality) + fiscally (cost) responsible to treat the defined population
- Fixed budget to a certain network, less profits
Contain costs + quality of care through a few mechanisms:
- Selective contracting ± payers negotiate prices + select local physicians + hospitals
- Steering ± send enrolees to selected providers
- Utilization reviews ± 3 types
1) Prospective (before care) ± mandatory second opinions for surgery +
preadmission certification
2) Concurrent (during care) ± occurs during hospitalization +assesses
appropriateness of treatment relative to diagnosis
3) Retrospective (after treatment) ± reviews treatment after discharge to
determine whether necessary and appropriate, used to verify services also
determine most cost-effective providers
- Selective contracting + steering are unique to managed care
- Utilization review can be used by all payers
Common characteristics:
- Most if not all care is provided in a network
- Resources are centralized in a network
HMO ± health management organization
- Few out of pocket expenses for patient (deductibles, co-insurance or copayments)
- All care must be provided in the network + primary care physician authorizes all services
- Assigned a physician (gate keeper) when join plan
- If services are provided but not authorized, patient is responsible
IPA ± independent practice associations
- Assign primary care physicians as gatekeeper for covered services, more common
Unlock document

This preview shows page 1 of the document.
Unlock all 3 pages and 3 million more documents.

Already have an account? Log in

Get OneClass Grade+

Unlimited access to all notes and study guides.

Grade+All Inclusive
$10 USD/m
You will be charged $120 USD upfront and auto renewed at the end of each cycle. You may cancel anytime under Payment Settings. For more information, see our Terms and Privacy.
Payments are encrypted using 256-bit SSL. Powered by Stripe.