Managed care
Download
1 / 109

MANAGED CARE - PowerPoint PPT Presentation


  • 167 Views
  • Uploaded on

MANAGED CARE. MANAGED CARE PLANS COMBINE THE DELIVERY OF HEALTH CARE WITH THE FINANCING OF THAT CARE.

loader
I am the owner, or an agent authorized to act on behalf of the owner, of the copyrighted work described.
capcha
Download Presentation

PowerPoint Slideshow about ' MANAGED CARE' - miller


An Image/Link below is provided (as is) to download presentation

Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author.While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server.


- - - - - - - - - - - - - - - - - - - - - - - - - - E N D - - - - - - - - - - - - - - - - - - - - - - - - - -
Presentation Transcript





Goals (Continued) RECEIVE.

Care is rendered by the most appropriate provider

Care is rendered in the most appropriate, least-restrictive environment







  • INDIVIDUAL PRACTICE ASSOCIATIONS (IPA’S) ARE A LESS RESTRICTIVE FORM OF HMO THAN THE GROUP OR STAFF MODEL.







    • POINT OF SERVICE (POS) CONTINUE TO SEE FEE-FOR-SERVICE PATIENTS IN THEIR OFFICE.

      • POINT OF SERVICE (POS) PLANS PERMIT MEMBERS GREATER CHOICE AND FLEXIBILITY BY ALLOWING YOU THE OPTION OF GOING “OUT OF PLAN” TO USE NON-HMO PROVIDERS.








    • DEFINED CARE PLANS IN SELECTING HEALTH CARE PROVIDERS BUT PPO PREMIUMS ARE USUALLY SOMEWHAT HIGHER THAN HMO PREMIUMS AND THERE IS LESS COORDINATION OF CARE.

    • Employer sponsored Defined Contribution Health plans.

    • Provides an allowance that empowers consumers to purchase and select from a wide menu of benefit options



    • RECEIVING CARE PLANS IN SELECTING HEALTH CARE PROVIDERS BUT PPO PREMIUMS ARE USUALLY SOMEWHAT HIGHER THAN HMO PREMIUMS AND THERE IS LESS COORDINATION OF CARE.

  • GATEKEEPERS







    • QUALITY REVIEW NECESSARY CARE AT THE LOWEST COST AND TO AVOID GIVING UNNECESSARY CARE.

  • UNDER TRADITIONAL HEALTH INSURANCE PLANS, DOCTORS PRACTICE INDEPENDENTLY WITH LITTLE OR NO ASSESSMENT OF THEIR PERFORMANCE BY THEIR PEERS OR GOVERNMENT REGULATORS.





    • UTILIZATION REVIEW GOVERNMENT OVERSIGHT, PATIENT SATISFACTION SURVEYS, DATA FROM GRIEVANCE PROCEDURES, AND INDEPENDENT REVIEWS.








    • SECOND SURGICAL OPINIONS: CASES TO BE SURE CARE IS COORDINATED AND PROVIDED IN THE MOST COST-EFFECTIVE MANNER.

    • PLANS MAY REQUIRE A SECOND OPINION BEFORE SCHEDULING ELECTIVE SURGERY. THE SECOND PHYSICIAN MAY BE ASKED TO JUDGE THE NECESSITY OF THE SURGERY AND ALSO TO EXPRESS AN OPINION ON THE MOST ECONOMICAL, APPROPRIATE PLACE TO PERFORM THE SURGERY.


    • PAYING FOR CARE CASES TO BE SURE CARE IS COORDINATED AND PROVIDED IN THE MOST COST-EFFECTIVE MANNER.





    • HMO STAFF MODEL: AND THERE IS FAR LESS PAPERWORK FOR PLAN MEMBERS TO CONTEND WITH.

      • PROS: CENTRALIZED FACILITY WHERE CARE IS PROVIDED AND COORDINATED; LOW COPAYMENTS; PREVENTATIVE CARE; NO CLAIM FORMS.

      • CONS: MUST USE DOCTOR IN THE HMO; PLAN MUST APPROVE TREATMENT AND MAKE REFERRALS.


    • HMO INDIVIDUAL PRACTICE ASSOCIATION: AND THERE IS FAR LESS PAPERWORK FOR PLAN MEMBERS TO CONTEND WITH.

      • PROS: PROVIDERS USE THEIR OWN OFFICES; LOW COPAYMENTS; PREVENTATIVE CARE; NO CLAIM FORMS.

        • CONS: MUST USE DOCTORS IN THE HMO; PLAN MUST APPROVE TREATMENT AND MAKE REFERRALS.


    • HMO POINT OF SERVICE: AND THERE IS FAR LESS PAPERWORK FOR PLAN MEMBERS TO CONTEND WITH.

      • PROS: MORE CHOICE OF PROVIDERS OUTSIDE THE NETWORK; LOWER COST WITHIN THE NETWORK; PREVENTIVE CARE COVERED.

      • CONS: HIGHER COST OUTSIDE THE NETWORK; OUT-OF-NETWORK COVERAGE MAY BE LIMITED; PLAN MUST SOMETIMES APPROVE TREATMENT AND MAKE REFERRALS.


    • PREFERRED PROVIDER ORGANIZATION (PPO): AND THERE IS FAR LESS PAPERWORK FOR PLAN MEMBERS TO CONTEND WITH.

      • PROS: CHOICE OF STAYING IN OR GOING OUT OF THE NETWORK FOR CARE. LOWER COST IF PROVIDERS WITHIN NETWORK ARE USED.

      • CONS: HIGH COST OUTSIDE THE NETWORK; ADDITIONAL PAPERWORK TO SECURE APPROVAL FOR SOME SERVICES; LIMITED COORDINATION OF CARE.


    • TRADITIONAL HEALTH INSURANCE: AND THERE IS FAR LESS PAPERWORK FOR PLAN MEMBERS TO CONTEND WITH.

      • PROS: UNRESTRICTED CHOICE OF PROVIDER.

      • CONS: USUALLY MORE EXPENSIVE; LITTLE OR NO COORDINATION OF CARE; PREVENTIVE CARE USUALLY NOT COVERED; CLAIM FORMS TO FILE.



    • MEMBERS: AND THERE IS FAR LESS PAPERWORK FOR PLAN MEMBERS TO CONTEND WITH.

  • IN MANAGED CARE EACH PATIENT WITH INSURANCE COVERAGE UNDER A HEALTH PLAN IS CALLED A MEMBER. OTHER TERMS INCLUDE ENROLLEES AND COVERED LIVES.




    • QUALITY MANAGEMENT WHICH MOST EXPENSE AND REVENUE, AND MANY UTILIZATION COMPARISONS ARE MADE.

      • INVOLVES ENSURING MEMBERS ARE GETTING ACCESSIBLE AND AVAILABLE CARE, DELIVERED WITHIN COMMUNITY STANDARDS; AND ENSURING A SYSTEM TO IDENTIFY AND CORRECT PROBLEMS, AND TO MONITOR ONGOING PERFORMANCE.


    • UTILIZATION MANAGEMENT WHICH MOST EXPENSE AND REVENUE, AND MANY UTILIZATION COMPARISONS ARE MADE.

      • INVOLVES COORDINATING HOW MUCH OR HOW CARE IS GIVEN FOR EACH PATIENT, AS WELL AS THE LEVEL OF CARE. THE GOAL IS TO ENSURE CARE IS DELIVERED COST-EFFECTIVELY, AT THE RIGHT LEVEL, AND DOESN’T USE UNNECESSARY RESOURCES.


    • OUTCOMES MANAGEMENT WHICH MOST EXPENSE AND REVENUE, AND MANY UTILIZATION COMPARISONS ARE MADE.

      • DETERMINES THE CLINICAL END-RESULTS ACCORDING TO DEFINED VARIOUS CATEGORIES AND THEN PROMOTE USE OF THOSE CATEGORIES WHICH YIELD IMPROVED OUTCOMES.


    • DEMAND MANAGEMENT WHICH MOST EXPENSE AND REVENUE, AND MANY UTILIZATION COMPARISONS ARE MADE.

      • A PROGRAM ADMINISTERED BY THE PROVIDER ORGANIZATION TO MONITOR AND PROCESS MANY TYPES OF INITIAL MEMBER REQUESTS FOR CLINICAL INFORMATION AND SERVICES.


    • DISEASE MANAGEMENT WHICH MOST EXPENSE AND REVENUE, AND MANY UTILIZATION COMPARISONS ARE MADE.

      • INVOLVES ASPECTS OF CASE AND OUTCOMES MANAGEMENT, BUT APPROACH FOCUSES ON SPECIFIC DISEASES, LOOKING AT WHAT CREATES THE COSTS, WHAT TREATMENT PLAN WORKS, EDUCATING PATIENTS AND PROVIDERS, AND COORDINATING CARE AT ALL LEVELS. HOSPITAL, PHARMACY, PHYSICIAN, ETC.



    • CAPITATION WHICH MOST EXPENSE AND REVENUE, AND MANY UTILIZATION COMPARISONS ARE MADE.

      • CAPITATION MEANS PAY A FIX AMOUNT OF MONEY PER PERSON (PER CAPITA). CAPITATION PUTS A LID ON PAYMENTS PER PERSON THAT OTHERWISE MIGHT CHANGE UNDER A FEE-FOR-SERVICE SYSTEM. PROVIDERS ARE AT FULL FINANCIAL RISK FOR THE SERVICES CAPITATED. THE PROVIDER IS PAID A FIX AMOUNT PER MEMBER ENROLLED, REGARDLESS OF THE NUMBER OF SERVICES DELIVERED TO THAT MEMBER.


    • WHAT THE FUTURE HOLDS WHICH MOST EXPENSE AND REVENUE, AND MANY UTILIZATION COMPARISONS ARE MADE.

    • RIGHT AROUND THE CORNER

    • Managed Care Backlash will become a permanent fixture, without producing radical reform.





    • LONGER TERM.. the labor market is tight.

    • When the economy diminishes, more proactive changes will occur.

    • Defined Care and consumerism will become a major factor.




    Managed care1

    MANAGED CARE medical management techniques.

    FACTS, TERMS, AND DEFINITIONS








    • OrganizationManaged Care enrollment – 100%

    • WellPoint, Inc. 27,236,851

    • UnitedHealth Group, Inc. 21,684,629

    • Aetna, Inc. 14,172,723

    • Health Care Service Corporation 12,262,905

    • CIGNA Health care, Inc. 9,064,024

    • Kaiser Permanente 8,825,581

    • Humana, Inc. 7,699,106

    • Blue Cross Blue Shield of Michigan 4,937,591

    • Highmark, Inc. 4,739,178

    • HIP Health Plan of New York 4,285,194

    • Total (for US) 206,226,739



    • AMBULATORY CARE – 100%

    • ALL TYPES OF HEALTH SERVICES THAT ARE PROVIDED ON AN OUTPATIENT BASIS, IN CONTRAST TO SERVICES PROVIDED IN THE HOME OR TO PERSONS WHO ARE HOSPITAL INPATIENTS.


    • CASE MANAGEMENT – 100%

    • THE PROCESS BY WHICH ALL HEALTH RELATED MATTERS OF A CASE ARE MANAGED BY A PHYSICIAN OR NURSE OR DESIGNATED HEALTH PROFESSIONAL. PHYSICIAN CASE MANAGERS COORDINATE DESIGNATED COMPONENTS OF HEALTH CARE, SUCH AS APPROPRIATE REFERRAL TO CONSULTANTS, SPECIALISTS, HOSPITALS, ANCILLARY PROVIDERS AND SERVICES.



    • COPAYMENT AND ACCESSIBILITY TO OVERCOME RIGIDITY, FRAGMENTED SERVICES, AND THE MISUTILIZATION OF FACILITIES AND RESOURCES.

    • A COST-SHARING ARRANGEMENT IN WHICH A MEMBER PAYS A SPECIFIED CHARGE FOR A SPECIFIED SERVICE. THE MEMBER IS USUALLY RESPONSIBLE FOR PAYMENT AT THE TIME THE SERVICE IS RENDERED.


    • COST SHARING AND ACCESSIBILITY TO OVERCOME RIGIDITY, FRAGMENTED SERVICES, AND THE MISUTILIZATION OF FACILITIES AND RESOURCES.

    • A GENERAL SET OF FINANCING ARRANGEMENTS IN WHICH A COVERED MEMBER MUST PAY A PORTION OF THE COSTS ASSOCIATED WITH RECEIVING CARE, E.G., CO-PAYMENT, COINSURANCE OR DEDUCTIBLE.


    • DIAGNOSIS RELATED GROUPS (DRG) AND ACCESSIBILITY TO OVERCOME RIGIDITY, FRAGMENTED SERVICES, AND THE MISUTILIZATION OF FACILITIES AND RESOURCES.

    • A SYSTEM OF CLASSIFICATION FOR INPATIENT HOSPITAL SERVICES BASED ON DIAGNOSIS, AGE, SEX, AND PRESENCE OF COMPLICATIONS. IT IS USED AS A MEANS OF IDENTIFYING COSTS FOR PROVIDING SERVICES ASSOCIATED WITH THE DIAGNOSIS AND AS A MECHANISM TO REIMBURSE HOSPITAL AND SELECTED OTHER PROVIDERS FOR SERVICES RENDERED.


    • FEE-FOR-SERVICE AND ACCESSIBILITY TO OVERCOME RIGIDITY, FRAGMENTED SERVICES, AND THE MISUTILIZATION OF FACILITIES AND RESOURCES.

    • A PAYMENT SYSTEM BY WHICH DOCTORS, HOSPITALS AND OTHER PROVIDERS ARE PAID A SPECIFIC AMOUNT FOR EACH SERVICE PERFORMED AS IT IS RENDERED AND IDENTIFIED BYA CLAIM FOR PAYMENT.


    • FORMULARY AND ACCESSIBILITY TO OVERCOME RIGIDITY, FRAGMENTED SERVICES, AND THE MISUTILIZATION OF FACILITIES AND RESOURCES.

    • A LIST OF SELECTED PHARMACEUTICALS AND THEIR APPROPRIATE DOSAGES FELT TO BE THE MOST USEFUL AND COST EFFECTIVE FOR PATIENT CARE. IN SOME MANAGED CARE PLANS, PROVIDERS ARE REQUIRED TO PRESCRIBE FROM THE FORMULARY.


    • GROUP OR NETWORK HMO AND ACCESSIBILITY TO OVERCOME RIGIDITY, FRAGMENTED SERVICES, AND THE MISUTILIZATION OF FACILITIES AND RESOURCES.

    • A MANAGED CARE ORGANIZATION IN WHICH THE MANAGED CARE ORGANIZATION CONTRACTS WITH MORE THAN ONE PHYSICIAN GROUP, AND MAY CONTRACT WITH SINGLE AND MULTI-SPECIALITY GROUPS THAT WORK OUT OF THEIR OWN OFFICE FACILITY. THE NETWORK MAY OR MAY NOT PROVIDE CARE EXCLUSIVELY FOR THE MANAGED CARE ORGANIZATION’S MEMBERS.


    • CENTER FOR MEDICARE AND MEDICAID AND ACCESSIBILITY TO OVERCOME RIGIDITY, FRAGMENTED SERVICES, AND THE MISUTILIZATION OF FACILITIES AND RESOURCES.

    • CMS IS THE FEDERAL AGENCY THAT ADMINISTERS THEMEDICARE AND MEDICAID PROGRAMS, AND WORKS TO ASSURE THAT THE BENEFICIARIES ENROLLED IN THESE PROGRAMS HAVE ACCESS TO HIGH QUALITY CARE.


    • INDEMNITY PLAN AND ACCESSIBILITY TO OVERCOME RIGIDITY, FRAGMENTED SERVICES, AND THE MISUTILIZATION OF FACILITIES AND RESOURCES.

    • A PLAN WHICH REIMBURSES PHYSICIANS FOR SERVICES PERFORMED, OR BENEFICIARIES FOR MEDICAL EXPENSES INCURRED (RETROACTIVE PAYMENT). SUCH PLANS ARE DIFFERENT FROM GROUP HEALTH PLANS, WHICH RECEIVE A SPECIFIC AMOUNT IN ADVANCE TO COVER ALL OR CERTAIN HEALTH CARE SERVICES FOR A SPECIFIC POPULATION (PROSPECTIVE PAYMENT).


    • INDIVIDUAL PRACTICE ASOCIATION (IPA) MODEL AND ACCESSIBILITY TO OVERCOME RIGIDITY, FRAGMENTED SERVICES, AND THE MISUTILIZATION OF FACILITIES AND RESOURCES.

    • A MANAGED CARE ORGANIZATION THAT CONTRACTS WITH INDIVIDUAL PRACTITIONERS OR AN ASSOCIATION OR INDIVIDUAL PRACTICES TO PROVIDE HEALTH CARE SERVICES IN RETURN FOR A NEGOTIATED FEE. THE INDIVIDUAL PRACTICE ASSOCIATION, IN TURN, COMPENSATES ITS PHYSICIANS ON A PER CAPITA, FEE SCHEDULE, OR OTHER AGREED-UPON BASIS.


    • LOCK-IN AND ACCESSIBILITY TO OVERCOME RIGIDITY, FRAGMENTED SERVICES, AND THE MISUTILIZATION OF FACILITIES AND RESOURCES.

    • A CONTRACTUAL PROVISION BY WHICH MEMBERS, EXCEPT IN CASES OF UNFORESEEN OUT-OF-AREA URGENTLY NEEDED CARE OR EMERGENCY CARE, ARE REQUIRED TO RECEIVE ALL THEIR CARE FROM THE MANAGED CARE PLAN’S NETWORK OF HEALTH CARE PROVIDERS.


    • MANAGED CARE ORGANIZATION AND ACCESSIBILITY TO OVERCOME RIGIDITY, FRAGMENTED SERVICES, AND THE MISUTILIZATION OF FACILITIES AND RESOURCES.

    • AN ENTITY THAT INTEGRATES FINANCING AND MANAGEMENT WITH THE DELIVERY OF HEALTH CARE SERVICES TO AN ENROLLED POPULATION. AN MCO PROVIDES, OFFERS, OR ARRANGES COVERAGE OF DESIGNATED HEALTH SERVICES NEEDED BY MEMBERS FOR A FIXED, PREPAID AMOUNT.


    • MEDICALLY NECESSARY AND ACCESSIBILITY TO OVERCOME RIGIDITY, FRAGMENTED SERVICES, AND THE MISUTILIZATION OF FACILITIES AND RESOURCES.

    • SERVICES OR SUPPLIES WHICH MEET THE FOLLOWING:

      • THEY ARE APPROPRIATE AND NECESSARY FOR THE SYMPTOMS, DIAGNOSIS, OR TREATMENT OF THE MEDICAL CONDITION;




    • MEDICARE MANAGED CARE PROVIDER;

    • MEDICARE MANAGED CARE IS A HEALTH CARE OPTION YOU CAN CHOOSE TO RECEIVE YOUR MEDICARE BENEFITS. MANAGED CARE PLANS HAVE CONTRACTS WITH THE GOVERNMENT, SPECIFICALLY THE HEALTH CARE FINANCING ADMINISTRATION, TO PROVIDE YOUR MEDICARE BENEFITS.


    • MEDICARE SUPPLEMENT INSURANCE PROVIDER;

    • PRIVATE HEALTH INSURANCE THAT PAYS CERTAIN COSTS NOT COVERED BY FEE-FOR-SERVICE MEDICARE, SUCH AS MEDICARE COINSURANCE AND DEDUCTIBLES.


    • POINT-OF-SERVICE (POS) OPTION PROVIDER;

    • A MEMBER’S OPTION TO CHOOSE TO RECEIVE A SERVICE FROM OUTSIDE THE PLAN’S NETWORK OF PROVIDERS FOR AN ADDITIONAL FEE SET BY THE PLAN. GENERALLY, THE LEVEL OF COVERAGE IS REDUCED FOR SERVICES ASSOCIATED WITH THE USE OF NON-PARTICIPATING PROVIDERS.


    • PREFERRED PROVIDERS PROVIDER;

    • PHYSICIANS, HOSPITALS, AND OTHER HEALTH CARE PROVIDERS WHO CONTRACT TO PROVIDE HEALTH SERVICES TO PERSONS COVERED BY A PARTICULAR HEALTH PLAN.


    • PREFERRED PROVIDER ORGANIZATION (PPO) PROVIDER;

    • A HEALTH CARE DELIVERY SYSTEM THAT CONTRACTS WITH PROVIDERS OF MEDICAL CARE TO PROVIDE SERVICES AT DISCOUNTED FEES TO MEMBERS. MEMBERS MAY SEEK CARE FROM NON-PARTICIPATING PROVIDERS BUT GENERALLY ARE FINANCIALLY PENALIZED FOR DOING SO BY THE LOSS OF THE DISCOUNT AND SUBJECTION TO COPAYMENTS AND DEDUCTIBLES.


    • PRIMARY CARE NETWORK (PCN) PROVIDER;

    • A GROUP OF PRIMARY CARE PHYSICIANS WHO SHARE THE RISK OF PROVIDING CARE TO MEMBERS OF A GIVEN HEALTH PLAN.


    • PRIMARY CARE PHYSICIANS (PCP) PROVIDER;

    • THE PHYSICAN THAT SERVES AS THE INITIAL CONTACT BETWEEN THE MEMBER AND THE MEDICAL CARE SYSTEM. THE PCP IS USUALLY A PHYSICIAN WHO IS TRAINED IN ONE OF THE PRIMARY CARE SPECIALITIES, AND WHO TREATS AND IS RESPONSIBLE FOR COORDINATING THE TREATMENT OF MEMBERS ASSIGNED TO HIS OR HER PANEL.


    • PROVIDER PROVIDER;

    • A HEALTH CARE PROVIDER OR FACILITY THAT IS PART OF THE MANAGED CARE PLAN’S NETWORK USUALLY HAVING FORMAL ARRANGEMENTS TO PROVIDE SERVICES TO THE PLAN’S MEMBERS.


    • QUALITY ASSURANCE PROVIDER;

    • A FORMAL METHODOLOGY AND SET OF ACTIVITIES DESIGNED TO ASSESS THE QUALITY OF SERVICES PROVIDED. QUALITY ASSURANCE INCLUDES FORMAL REVIEW OF CARE, PROBLEM IDENTIFICATION, AND CORRECTIVE ACTIONS TO REMEDY ANY DEFICIENCIES AND EVALUATION OF ACTIONS TAKEN.


    • STAFF MODEL PROVIDER;

    • THIS MANAGED CARE ORGANIZATION MODEL EMPLOYS PHYSICIANS TO PROVIDE HEALTH CARE TO ITS MEMBERS. ALL PREMIUMS AND OTHER REVENUES ACCRUE TO THE MANAGED CARE ORGANIZATION, WHICH COMPENSATES PHYSICIANS BY SALARY.



    ad