Managed Care

1. Managed Care

2. Managed Care • In the broadest terms, Kongstvedt (1997) describes managed care as a system of healthcare delivery that tries to manage the cost of healthcare, the quality of that healthcare and access to that care.

3. Characteristics of Managed Care • Managed care is a system that integrates the financing and delivery of appropriate medical care by means of: • Contracting selected MDs & hospitals to furnish comprehensive care • Setting a predetermined monthly, premium fee for services, • Incorporating financial incentives to encourage patients to use only resources in the plan. • Having physicians assume some financial risk for their work --thus the role changes from advocacy to allocation (gatekeeper), and • Monitoring health care providers for quality assurance and utilization management.

4. Characteristics of Managed Care Plans Versus Traditional Indemnity Insurance

5. Common characteristics of managed care plans

6. Common characteristics of managed care plans

7. Differences Between Managed Careand Fee-For-Service Coverage • The most important characteristic that distinguishes managed care from other forms of health insurance is the active influence on medical decision-making through: • Dissemination of clinical guidelines, • Pre-authorization programs for referrals, admissions, and diagnostic testing, • Creation of limited provider networks whose members agree to adhere to the practice standards developed by the plan.

8. Managed Care Organizations (MCOs) • MCOs are formal arrangements whereby distinct organizations are made responsible for managing a network of services and supports and are accountable for network performance. • These operational responsibilities are separate and distinct from the policy-level responsibilities of the public agency charged with governing the system. • As a rule, managed care organizations are responsible for keeping spending within established limits.

9. Managed Care Organization Continuum • Managed care plans are sometimes described as either loosely or tightly managed, indicating how much they actually manage the care of their members.

10. Managed Care Organization Continuum • A loosely managed program might allow a member to: • Receive specialty care without approval from his/her PCP, • Seek care from a physician who is not part of the plan’s network and have the care at least partially paid for by the plan benefit, • Obtain care at urgent care centers without preauthorization.

11. Managed Care Organization Continuum • A tightly managed program however, would require a member to: • Select a PCP from providers affiliated with the health plan, • Seek routine care from his/her PCP, • Seek prior authorization for urgent/emergent care that is not life threatening, • Request referral for specialty care services from his/her PCP.

12. Managed Care Continuum Use of Managed Care Techniques Less More Traditional Indemnity Health Plan Traditional with Cost Containment POS PPO HMO

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