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38 Cards in this Set

  • Front
  • Back
The purchase of one organization over another
An agreement between two organizations to share resources without joint ownership of assets. Simpler than mergers
A policy meant to ensure competition by preventing large medical systems from monopolizing health care markets.
any willing provider laws
Laws that prevent powerful MCO administrators from deliberately excluding a qualified physician from their plans. They can undermine price competition by forcing MCOs to contract with more, and worse, physicians than necessary
a payment arrangement under which the provider is paid a monthly sum per enrollee (PMPM) regardless of the enrollee’s utilization. Risk is shifted from the MCO to the provider
carve out
Specialty services that are not included in a regular plan and must be specially contracted.
case management
When an experienced, specially-trained health care professional monitors a patient’s care.
closed panel
Not allowing enrollees to use providers not contracted by the MCO
The concentration of control by a few organizations over others. Examples are acquisitions, mergers, alliances, networks.
discharge planning
used in utilization review. includes an estimate of the length of patient’s hospital stay, the expected outcome, and the need for special requirements at discharge.
The addition of new services through consolidation, expansion, or conversion of unused facilities.
The addition of new services or services similar to old ones by building new facilities.
fee schedule
a schedule of pre-negotiated fees paid to the provider by the MCO (usually at discounted rates).
gag rules
Clauses in managed care contracts that prohibit providers from fully disclosing all treatment options to a patient. A rare problem.
group model
An HMO model. The HMO contracts with a multi-specialty group practice and also with a hospital. The HMO pays a capitation fee.
Health maintenance organization. An MCO that is identified by wellness care, capitation, a closed panel, and accountability.
horizontal integration
A geographic mode of expansion in which an organization extends its products/services.
independent practice association
see IPA model.
integrated delivery system
Ideally, a network of organizations that provides a coordinated continuum of services to a population and can be held clinically and fiscally accountable for the heath outcomes/status of a population.
Organization integration aims to provide a seamless array of services around a central hospital.
IPA model
Independent Practice Association Model. An intermediary representing a large number of physicians that is paid a capitation amount by the MCO. A legal entity that contracts with both independent physicians and group practices.
joint venture
When 2+ insitutions share resources to create a new organization to pursue a common purpose.
The unification of 2+ organizations to form a single entity.
mixed model
An HMO model that mixes any of the four models (staff, group, network, IPA).
Management services organizations are used by independent physician groups who don’t want to employ full-time managers.
network model
an HMO model. The HMO contracts with more than one medical group practice. Good for large metropolitan areas and widespread geographic regions.
open panel
allowing access to providers outside the MCO’s panel, but at a higher cost
the group of physicians who have formal affiliations/contracts with the MCO
Preferred Provider Organization. Used initially by insurance companies to compete with MCOs. Has an open-panel option, but preferred providers have discounted fees. Insurance company reimburses patients, so out-of-pocket expenses are possible. Does not use gate-keeping.
practice profiling
the determination of provider-specific practice patterns and the comparison of these patterns to the norm. can be used to give feedback to provider, identify structural problems, etc.
primary care case management
PCCM. A variation of managed care used by Medicaid. The state contracts directly with primary care providers who act as case managers. PCPs are paid on a fee-for-service basis.
A provider-sponsored organization is a risk-bearing entity sponsored by physicians and hospitals that contracts directly with enrollees, bypassing MCO. Basically a PHO.
risk adjustment
Adjusting premium payments to reflect the patient’s health status (and thus utilization). Protects against adverse risk-selection.
risk contract
A Medicare managed care contract in which the MCO is liable for Plan B (outpatient) services in exchange for a capitated fee.
staff model
an HMO model. The HMO employs its own physicians and operates its own ambulatory care facilities. It pays a fixed salary with bonuses based on performance. It contracts with hospitals for inpatient services.
utilization review
The process of evaluating the appropriateness of services provided (looks at utilization, cost-efficiency). three categories: prospective, concurrent, and retrospective
vertical integration
A diversification strategy in which an organization increases the comprehensiveness and continuity of care by linking services at different stages in the health care delivery process.
virtual integration
The formation of networks based on contractual arrangements. Example: IPA