Session 10
Read Chapter 8 and review these slides. (Note: the slide label is not the same as the chapter of the same title, but the content is correct.)
OBJECTIVES OF CHAPTER 8: Students will describe
- Managed care and its growth.
- The formation of health networks.
Focus on:
- Main Characteristics of Managed Care
- Evolution and Growth of managed care
- Utilization Control
- Cost, Access, and Quality
This chapter and slide show focus on the current financing organization of the US health care system utilized by the hundreds of individual insurance and reimbursement organizations and the Federal government. Because the Medicare and Medicaid programs, cover a significant minority of the population, the reimbursement coverage of its defined populations serve as a pattern for the rest of the insurance (third part reimbursers/payors.) Despite the name, this has little to do with management of care, but with limitations of payment. This system is dominated by the hospital industry with office based physicians having little impact.
Terms you should know:
- Alliance: An agreement between two or more organizations to share their resources without joint ownership of assets.
- Capitation: Payment of a fixed amount per enrollee (per member per month) to cover all services the enrollee may need.
- Carve out: A special contract to cover specialized services which are funded by a managed care organization separately from regular capitation.
- Discharge planning includes an estimate of how long a patient will be in the hospital, what the outcome is likely to be, and whether there will be any special requirements at discharge.
- Gatekeeping: An arrangement in which a primary care physician coordinates all health care services needed by an enrollee.
- Horizontal integration: Expansion of an organization into its existing core product or service.
- Joint venture: Two or more institutions share ownership in a new organization created to pursue a common purpose.
- Merger: Two organizations agree to unify by bringing their assets together and operate under a new name.
- Pre-certification: Obtaining pre-approval for certain services from the plan administrators.
- Physician-Hospital Organizations (PHOs) are formed through legal alliances between hospitals and physicians.
- Underutilization occurs when medically necessary care is not delivered.
- Utilization review is the process of evaluating the appropriateness of services provided.
- Vertical integration links services that are at different stages in the production process of health care, for example, organization of preventive services, primary care, acute care, and post acute service delivery around a hospital.
- Virtual integration: A health care network created through contractual arrangements.
- Virtual Organization: A virtual organization is formed when two or more organizations create a new entity through contractual arrangements
Following this reading and slide show you should be able to discuss the following in 200 or less words:
- What is capitation? How does this payment arrangement share risk with providers?
- What is gatekeeping? Briefly explain how it works
- hat main effects on health care delivery have been produced by the integration of organizations into health networks?
Feel free to past an answer on the Discussion Forum for review and comment by your peers.