MANAGED CARE

1

• MANAGED CARE

2

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

3

• IN A MANAGED CARE PLAN, SUCH AS A HEALTH
  MAINTENANCE ORGANIZATION (HMO) OR A PREFERRED
  PROVIDER ORGANIZATION (PPO), YOU RECEIVE YOUR
  HEALTH CARE FROM A GROUP OF PHYSICIANS,
  HOSPITALS, AND OTHER SERVICE PROVIDERS SELECTED
  BY THE PLAN.

4

• IN EXCHANGE, YOU PAY A SET MONTHLY FEE FOR THE
  SERVICES YOU RECEIVE.

5

• Goals of Managed Health Care Plans
• Provide high quality care in an environment that
  controls cost
• Care is medically necessary and appropriate

6

• Goals (Continued)
• Care is rendered by the most appropriate
  provider
• Care is rendered in the most appropriate,
  least-restrictive environment

7

• TYPES OF MANAGED CARE PLANS

8

• HEALTH MAINTENANCE ORGANIZATION

9

• GROUP AND STAFF MODEL HMOS ARE THE MOST
  RESTRICTIVE AND PROVIDE FEWER CHOICES OF
  PROVIDERS TO CONSUMERS.

10

• ON THE OTHER HAND, THIS MODEL OFTEN OFFERS
  ONE-STOP CARE WHICH MEANS THAT ALL YOUR DOCTORS,
  AS WELL AS LABORATORY AND X-RAY SERVICES ARE
  X-RAY SERVICES ARE LOCATED IN ONE MEDICAL
  FACILITY.

11

• IN A GROUP OR STAFF HMO, YOU MUST CHOOSE A
  PRIMARY PHYSICIAN. IF YOU DONT, THEY WILL
  CHOOSE ONE FOR YOU.

12

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

13

• INDIVIDUAL PHYSICIANS PRACTICING IN THEIR OWN
  OFFICES ARE UNDER CONTRACT TO A SEPARATE GROUP,
  CALLED AN IPA THAT, IN TURN, CONTRACTS WITH AN
  HMO.

14

• THE HMO PROVIDES YOU WITH A LIST OF PARTICIPATING
  PHYSICIANS FROM WHICH YOU MAY CHOOSE YOUR PRIMARY
  CARE DOCTOR.

15

• VISITS TAKE PLACE IN THE DOCTORS OFFICE. IF YOU
  REQUIRE SPECIALITY CARE, YOUR PRIMARY CARE DOCTOR
  REFERS YOU TO A PARTICIPATING SPECIALIST.

16

• BY FAR THE LARGEST NUMBER OF HMO MEMBERS ARE
  ENROLLED IN THE IPA MODEL.

17

• PHYSICIANS MAY BELONG TO MORE THAN ONE HMO AND
  ALSO MAY CONTINUE TO SEE FEE-FOR-SERVICE PATIENTS
  IN THEIR OFFICE.

18

• POINT OF SERVICE (POS)
• 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.

19

• IF YOU GO OUT OF PLAN, YOU MUST PAY MORE,
  TYPICALLY IN THE FORM OF HIGH COINSURANCE AND
  DEDUCTIONS.

20

• PREFERRED PROVIDER ORGANIZATION (PPO)

21

• PREFERRED PROVIDER ORGANIZATION (PPO) ARE
  NETWORKS OF DOCTORS AND HOSPITALS THAT HAVE
  AGREED TO GIVE THE SPONSORING ORGANIZATION
  DISCOUNTS ON THEIR USUAL RATES. (USUALLY AN
  EMPLOYER OR INSURANCE COMPANY).

22

• SOME PPOS USE PRIMARY CARE PHYSICIANS AS
  GATEKEEPERS.

23

• IN OTHERS, YOU MAY CHOOSE YOUR OWN DOCTORS AND
  VISIT SPECIALISTS WITHOUT PERMISSION FROM A
  GATEKEEPER.

24

• PPOS OFFER YOU THE GREATEST FREEDOM AMONG
  MANAGED CARE PLANS IN SELECTING HEALTH CARE
  PROVIDERS BUT PPO PREMIUMS ARE USUALLY SOMEWHAT
  HIGHER THAN HMO PREMIUMS AND THERE IS LESS
  COORDINATION OF CARE.

25

• DEFINED CARE
• Employer sponsored Defined Contribution Health
  plans.
• Provides an allowance that empowers consumers to
  purchase and select from a wide menu of benefit
  options

26

• MANAGED CARE VS. TRADITIONAL HEALTH INSURANCE

27

• RECEIVING CARE
• GATEKEEPERS

28

• UNDER FEE-FOR-SERVICE INSURANCE OR TRADITIONAL
  HEALTH INSURANCE, YOU CAN CHOOSE ANY LICENSED
  PHYSICIAN TO BE YOUR PERSONAL DOCTOR AND YOU CAN
  THE SERVICES OF ANY HEALTH CARE FACILITY OR
  SERVICES.

29

• UNDER MANAGED CARE, MEMBERS RECEIVE CARE THAT IS
  PROVIDED DIRECTLY OR AUTHORIZED BY THE MANAGED
  CARE PLAN.

30

• THE PRIMARY CARE DOCTOR YOU CHOOSE BECOMES YOUR
  PERSONAL PHYSICIAN AND COORDINATES YOUR CARE.

31

• THE DOCTOR ACTS A GATEKEEPER, TREATING YOU
  DIRECTLY OR AUTHORIZING YOU TO HAVE TESTS, SEE A
  SPECIALIST, OR ENTER A HOSPITAL.

32

• THE GATEKEEPER ARRANGEMENT IS DESIGNED TO
  PROVIDE THE NECESSARY CARE AT THE LOWEST COST AND
  TO AVOID GIVING UNNECESSARY CARE.

33

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

34

• MANAGED CARE PLANS USUALLY HAVE QUALITY REVIEW
  PROCEDURES THAT MAY INCLUDE INTERNAL AND EXTERNAL
  QUALITY ASSURANCE PROGRAMS.

35

• PLANS FEDERALLY QUALIFIED TO PROVIDE HEALTH
  CARE TO MEDICARE OR MEDICAID ENROLLEES, UNDER LAW
  MUST HAVE QUALITY ASSURANCE PROGRAMS.

36

• THE OVERALL PERFORMANCE OF THE PLAN IS MONITORED
  THROUGH GOVERNMENT OVERSIGHT, PATIENT
  SATISFACTION SURVEYS, DATA FROM GRIEVANCE
  PROCEDURES, AND INDEPENDENT REVIEWS.

37

• UTILIZATION REVIEW

38

• MANAGED CARE PLANS REVIEW THE MEDICAL CARE
  PROVIDED BY YOUR DOCTORS TO DETERMINE WHETHER OR
  NOT IT IS APPROPRIATE AND NECESSARY.

39

• WHEN HOSPITAL CARE IS INDICATED, OTHER FACTORS
  AND SAFEGUARDS IN THE UTILIZATION REVIEW INCLUDE

40

• CARE IN ADVANCE. WITHOUT IT, THE PLAN MAY
  PREADMISSION CERTIFICATION APPROVAL FOR NOT PAY
  FOR NON-EMERGENCY SERVICES.

41

• CONCURRENT REVIEW MANAGED CARE PLANS MONITOR
  YOUR HOSPITAL STAYS TO BE SURE THEY ARE NO LONGER
  THAN ABSOLUTELY NEEDED AND THAT ALL TESTS AND
  PROCEDURES ORDERED ARE MEDICALLY NECESSARY.

42

• DISCHARGE PLANNING PLANS WANT TO KEEP HOSPITAL
  STAYS TO THEIR SHORTEST APPROPRIATE LENGTH. IF
  NECESSARY, THE PLAN WILL ARRANGE POST-HOSPITAL
  CARE, INCLUDING NURSING HOME OR HOME HEALTH CARE.

43

• CASE MANAGEMENT CASE PLANS ARE DEVELOPED FOR
  COMPLICATED CASES TO BE SURE CARE IS COORDINATED
  AND PROVIDED IN THE MOST COST-EFFECTIVE MANNER.

44

• SECOND SURGICAL OPINIONS
• 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.

45

• PAYING FOR CARE

46

• FOR MOST PEOPLE WITH TRADITIONAL HEALTH
  INSURANCE, PREMIUMS ARE ONLY ONE PART OF THE
  COST. CONSUMERS ALSO PAY DEDUCTIBLES,
  COINSURANCE, AND THE COST OF SERVICES THAT ARE
  NOT COVERED.

47

• WITH MANAGED CARE, OUT-OF-POCKET COSTS ARE
  GENERALLY LOWER, AND THERE IS FAR LESS PAPERWORK
  FOR PLAN MEMBERS TO CONTEND WITH.

48

• THE PROS AND CONS

49

• HMO STAFF MODEL
• 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.

50

• HMO INDIVIDUAL PRACTICE ASSOCIATION
• 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.

51

• HMO POINT OF SERVICE
• 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.

52

• PREFERRED PROVIDER ORGANIZATION (PPO)
• 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.

53

• TRADITIONAL HEALTH INSURANCE
• PROS UNRESTRICTED CHOICE OF PROVIDER.
• CONS USUALLY MORE EXPENSIVE LITTLE OR NO
  COORDINATION OF CARE PREVENTIVE CARE USUALLY NOT
  COVERED CLAIM FORMS TO FILE.

54

• KEY TERMS AND CONCEPTS

55

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

56

• PER MEMBER PER MONTH IS A RELATIVE MEASURE, THE
  RATIO, BY WHICH MOST EXPENSE AND REVENUE, AND
  MANY UTILIZATION COMPARISONS ARE MADE.

57

• MEDICAL MANAGEMENT TERMS

58

• QUALITY MANAGEMENT
• 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.

59

• UTILIZATION MANAGEMENT
• 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 DOESNT
  USE UNNECESSARY RESOURCES.

60

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

61

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

62

• DISEASE MANAGEMENT
• 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.

63

• SHARING FINANCIAL RISK

64

• CAPITATION
• 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.

65

• WHAT THE FUTURE HOLDS
• RIGHT AROUND THE CORNER
• Managed Care Backlash will become a permanent
  fixture, without producing radical reform.

66

• However, pharmaceutical costs may surpass managed
  care backlash in the number one health care
  public hot seat.
• PPO and Point of Service enrollment gains will
  continue.

67

• HMOS will continue to soften management
  techniques
• Plan premium provider costs increases will
  continue
• Provider clout over health plans will continue to
  solidify.

68

• Employers will grudgingly accept price increases
  as long as the labor market is tight.
• Medicare HMOs wont disappear despite pundits
  warnings to the contrary.

69

• LONGER TERM..
• When the economy diminishes, more proactive
  changes will occur.
• Defined Care and consumerism will become a major
  factor.

70

• New medical technology advancements will dictate
  future medical management techniques.
• Legislative reform will remain incremental, not
  radical, unless there is a devastating recession
  where uninsured numbers swell.

71

• End of lecture for Monday, October 19th, 2009,
  6th Period
• Questions?

72
MANAGED CARE

• FACTS, TERMS, AND DEFINITIONS

73

• FACTS ABOUT MANAGED CARE

74

• NUMBER OF HMOS IN THE UNITED STATES 574
• NUMBER OF PPOS IN THE UNITED STATES 1036
• NUMBER OF AMERICANS IN HMOS 79.3 MILLION

75

• NUMBER OF AMERICANS IN PPOS 89.1 MILLION
• NUMBER OF AMERICANS IN ALL MANAGED CARE PROGRAMS
  206 MILLION
• PERCENTAGE OF INSURED EMPLOYEES IN MANAGED CARE
  HEALTH PLANS 66

76

• PERCENTAGE OF MEDICARE ENROLLEES IN HMOS 9
• PERCENTAGE OF MEDICAID ENROLLEES IN HMOS 19.4
• PERCENTAGEOF MDS WITH AT LEAST ONE MANAGED CARE
  CONTRACT 75

77

• PERCENTAGE OF MDS WITH AT LEAST ONE HMO CONTRACT
  48
• PERCENTAGE OF HMOS THAT ARE FOR-PROFIT 69
• PERCENTAGE OF HMOS THAT ARE NOT-FOR-PROFIT 42.2
  

78

• PERCENTAGE OF HMOS WITH LISTS OF APPROVED
  PRESCRIPTION DRUGS 100

79

• OrganizationManaged Care enrollment
• 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

80
(No Transcript)
81

• MANAGED CARE TERMS

82

• AMBULATORY CARE
• 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.

83

• CASE MANAGEMENT
• 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.

84

• CASE MANAGEMENT IS INTENDED TO ENSURE CONTINUITY
  OF SERVICES AND ACCESSIBILITY TO OVERCOME
  RIGIDITY, FRAGMENTED SERVICES, AND THE
  MISUTILIZATION OF FACILITIES AND RESOURCES.

85

• COPAYMENT
• 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.

86

• COST SHARING
• 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.

87

• DIAGNOSIS RELATED GROUPS (DRG)
• 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.

88

• FEE-FOR-SERVICE
• 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.

89

• FORMULARY
• 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.

90

• GROUP OR NETWORK HMO
• 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
  ORGANIZATIONS MEMBERS.

91

• CENTER FOR MEDICARE AND MEDICAID
• 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.

92

• INDEMNITY PLAN
• 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).

93

• INDIVIDUAL PRACTICE ASOCIATION (IPA) MODEL
• 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.

94

• LOCK-IN
• 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
  PLANS NETWORK OF HEALTH CARE PROVIDERS.

95

• MANAGED CARE ORGANIZATION
• 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.

96

• MEDICALLY NECESSARY
• SERVICES OR SUPPLIES WHICH MEET THE FOLLOWING
• THEY ARE APPROPRIATE AND NECESSARY FOR THE
  SYMPTOMS, DIAGNOSIS, OR TREATMENT OF THE MEDICAL
  CONDITION

97

• THEY ARE PROVIDED FOR THE DIAGNOSIS OR DIRECT
  CARE AND TREATMENT OF MEDICAL CONDITIONS
• THEY MEET THE STANDARDS OF GOOD MEDICAL PRACTICE
  WITHIN THE MEDICAL COMMUNITY OF THE SERVICE AREA

98

• THEY ARE NOT PRIMARILY FOR THE CONVENIENCE OF THE
  PATIENT OR PROVIDER
• THEY ARE THE MOST APPROPRIATE LEVEL OR SUPPLY OF
  SERVICE WHICH CAN SAFELY BE PROVIDED.

99

• MEDICARE MANAGED CARE
• 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.

100

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

101

• POINT-OF-SERVICE (POS) OPTION
• A MEMBERS OPTION TO CHOOSE TO RECEIVE A SERVICE
  FROM OUTSIDE THE PLANS 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.

102

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

103

• PREFERRED PROVIDER ORGANIZATION (PPO)
• 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.

104

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

105

• PRIMARY CARE PHYSICIANS (PCP)
• 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.

106

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

107

• QUALITY ASSURANCE
• 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.

108

• STAFF MODEL
• 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.

109

• End of lecture for 6th Period, October 21st -
  2009
• Questions?