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FUNDAMENTALS OF MANAGED CARE. HIV/AIDS BUREAU HEALTH RESOURCES AND SERVICES ADMINISTRATION. FUNDAMENTALS OF MANAGED CARE. 1. Managed Care Elements 2. Organizational Models 3. Continuum of Managed Care 4. Functions of MCOs 5. Collaborative Organizations

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FUNDAMENTALS OF MANAGED CARE

HIV/AIDS BUREAU

HEALTH RESOURCES AND

SERVICES ADMINISTRATION

HRSA HIV/AIDS Bureau

fundamentals of managed care
FUNDAMENTALS OF MANAGED CARE

1. Managed Care Elements

2. Organizational Models

3. Continuum of Managed Care

4. Functions of MCOs

5. Collaborative Organizations

6. Utilization and Quality Management

7. Information Requirements

HRSA HIV/AIDS Bureau

slide3

MCE

  • IPA

PCCM

HMOS

MCO

THE ALPHABET SOUP OF MANAGED CARE

SSO

IDS

POS

  • MCP

PPO PHO

TPA

ISN

IPO

HRSA HIV/AIDS Bureau

managed care elements
MANAGED CARE ELEMENTS
  • Combinesfinancing and delivery systems
  • Patients are enrolled in a managed care plan on a prepaid basis with a defined benefit package that includes preventive and primary care services
  • Patients select (or assigned) a primary care provider (PCP) who acts as a gatekeeper to coordinate specialty and hospital care
  • Utilization and clinical practice are reviewed to contain costs while improving health status
  • Providers typically paid on a capitation basis but can be paid fee-for-service (FFS)

HRSA HIV/AIDS Bureau

organizational perspective

State (or employer)

State (or employer)

Managed Care

Organization (MCO)

Managed Care

Organization (MCO)

Inpatient

Providers

Inpatient

Providers

Primary Care

Providers

Primary Care

Providers

Specialty/Other

Providers

Specialty/Other

Providers

ORGANIZATIONAL PERSPECTIVE

Premium $$$$

$$$$

$$$$

$$$

HRSA HIV/AIDS Bureau

the continuum of managed care
THE CONTINUUM OF MANAGED CARE

Fee for Service Capitated

More Freedom of Choice Less Choice

More Expensive Less Expensive

INDEMNITY HMOS

Traditional Managed PPO POS IPA/Network Group Staff

HRSA HIV/AIDS Bureau

hmo models
HMO MODELS
  • STAFF Physicians are employees of the HMO
  • GROUP Physicians are members of a multi-specialty or single specialty group practice which in turn contracts with the HMO
  • IPA Either the individual physician contracts directly with the HMO or the individual physician is part of a physician corporation which contracts with the HMO
  • NETWORK The HMO contracts with group practices, IPA-physician corporations and/or individual physicians

HRSA HIV/AIDS Bureau

other managed care models
OTHER MANAGED CARE MODELS
  • POINT OF SERVICE (POS)
    • HMO offers members option to receive services from non-network providers at a reduced level of coverage
  • PREFERRED PROVIDER ORGANIZATION (PPO)
    • A system which contracts with providers at discounted fees
    • Members may seek care from non-participating providers but at higher copays or deductibles
  • MANAGED INDEMNITY
    • Fee for service insurance plan
    • Members receive services from any provider with some restrictions on utilization and cost e.g. pre-authorization; maximum fee schedule

HRSA HIV/AIDS Bureau

functions of mcos
FUNCTIONS OF MCOs
  • MARKETING
    • Private (small, large, federal groups), Individual, Medicaid, Medicare
  • MEMBERSHIP ACCOUNTING
    • Group billing and contracts
    • Enrollment & disenrollment; pcp assignment
  • NETWORK OPERATIONS
    • Provider credentialing and contracting, provider services
  • MEMBERSHIP SERVICES
    • Inquiries, education, grievances

HRSA HIV/AIDS Bureau

functions continued
FUNCTIONS CONTINUED
  • CLAIMS ADMINISTRATION
    • In vs Out of Network; physician vs institution
    • Incurred But Not Reported (IBNR) Claims
  • MANAGEMENT INFORMATION SYSTEMS
    • Reports for all departments
  • FINANCE
    • budget projections, premium calculations, capitation rates
  • UTILIZATION MANAGEMENT and QUALITY ASSURANCE

HRSA HIV/AIDS Bureau

collaborative organizations
COLLABORATIVE ORGANIZATIONS
  • INTEGRATED SERVICE NETWORK (ISN) - a collaboration of either primary care providers (horizontal) or primary, specialty and inpatient providers (vertical) for managed care purposes
  • PHYSICIAN HOSPITAL ORGANIZATION (PHO) - legal entity between hospital & MDs to contract with MCOs
  • SHARED SERVICES ORGANIZATION (SSO) - a collaboration between several organizations, such as community health centers, to share administrative, MIS, medical management and other services in order to participate in managed care (also TPA -third party administrators)

HRSA HIV/AIDS Bureau

utilization management
UTILIZATION MANAGEMENT
  • GOALS
    • plan members receive medically necessary & cost effective care;
    • utilization and cost patterns of participating providers are within defined limits;
    • plan meets its utilization and cost projections.
  • COMPONENTS
    • Referral Process
    • Prior or Pre-authorization:
    • Concurrent Review
    • Formulary
    • Medical Claims Review
    • Physician Selection/Physician Profiling

HRSA HIV/AIDS Bureau

quality management
QUALITY MANAGEMENT
  • GOALS
    • Healthcare services are available, accessible & acceptable and meet defined standards for medically appropriate care
    • Participating providers meet credential criteria
    • Health outcomes monitored & meet established criteria
  • QUALITY STUDIES
    • Chart Reviews/audits
    • Incident or complaint investigation
    • Specific disease or condition investigation
    • Population wide studies
  • PROVIDER AND STAFF EDUCATION
  • PATIENT SATISFACTION SURVEYS
  • ACCESS STANDARDS REVIEW

HRSA HIV/AIDS Bureau

national committee for quality assurance ncqa
NATIONAL COMMITTEE FOR QUALITY ASSURANCE (NCQA)
  • Private, not for profit organization; goal is to assess & report on quality of MCP
  • Two Major Activities: Accreditation and HEDIS
  • Accreditation:
    • Evaluates how well a MCP manages its delivery system
    • Reviews quality improvement, physician credentialing, member’s rights & responsibilities; preventive health services; utilization management and medical records
    • Becoming a Standard - many plans are seeking NCQA credentialling and growing list of employers require it

HRSA HIV/AIDS Bureau

hedis
HEDIS
  • Health Plan Employer Data & Information Set
    • Current version is 3.0 which includes commercial Medicaid & Medicare sectors
  • Key Performance Measures - clinical quality, access, member satisfaction, utilization and plan financial performance
  • Quality of Care Measures - include immunization rates; cervical cancer screening; asthma inpatient admission rate;
  • Only I AIDS measure in testing phase - PCP prophylaxis

HRSA HIV/AIDS Bureau

information requirements
INFORMATION REQUIREMENTS
  • Three key areas of data:
    • Enrollment, utilization, and cost
  • Accurate and timely information is crucial
  • Data helps staff to manage utilization and risk
  • Information provides the foundation for future planning

HRSA HIV/AIDS Bureau

types of reports
TYPES OF REPORTS
  • MEMBERSHIP
    • Accurate and timely membership report of enrolled and disenrolled members
  • CAPITATION
    • Compare capitation revenue to cost of providing service
  • AGGREGATE UTILIZATION AND COST
    • Compare projected versus actual utilization and cost
  • INDIVIDUAL PROVIDER UTILIZATION AND COST
    • Utilization and cost patterns for each primary care provider

HRSA HIV/AIDS Bureau

selected data elements
SELECTED DATA ELEMENTS

Data Element You Provide Managed Care Plan Provides

  • Member MonthsX
  • Capitation Revenue PMPM X
  • Primary Care Visits PMPM X
  • Cost of Primary Care PMPM X
  • Specialty Visits PMPM X
  • Ancillary Tests PMPM X
  • # of Primary Care Visits Per Provider X
  • # of Referrals per Provider X
  • # of Hosp/ital Admissions per Provider X

HRSA HIV/AIDS Bureau

ryan white programs versus mcos
RYAN WHITE PROGRAMS

public health mission

population driven

enabling services

medically and culturally appropriate providers

provide care to uninsured

accessible sites

experience with vulnerable populations

MCOs

for profit mission

market driven

mandated benefits only

cost efficient contracted providers

care only to members

“commercial” sites

experience with middle class

RYAN WHITE PROGRAMS VERSUS MCOs

HRSA HIV/AIDS Bureau

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