Health Policy And Management Chapter 9

Front 1

PPO (Preferred Provider Organization)

Back 1

first appeared as a competitive response by insurance companies to HMO's growing market share; they offered open-panel options for enrollees and offers noncapitation payment to providers; main appeal of PPOs is that they allow patients the choice of using physicians and hospitals outside the panel; PPO reimburses the patient for covered services obtained from any provider; most PPOs are owned by insurance companies, independent investors, and hospital alliances

Front 2

Point-of-service plan

Back 2

combine features of classic HMOs with some of the characteristics of patient choice found in PPOs; have 2 pronged objectives: retain the benefits of tight utilization management found in HMOs but offer an alternative to their unpopular feature of restricted choice

Front 3

Managed Care

Back 3

organized approach to delivering a comprehensive array of health care services to a group of enrolled members through efficient management of services needed by the members, and negotiation of prices or payment arrangements with providers; generally discussed in two contexts; it refers to a mechanism or process of providing health care services and has two main features: 1. Managed care integrates the functions of financing, insurance, delivery, and payment within one organizational setting 2. managed care exercises formal control over utilization

Front 4

Growth of managed care in the US was spurred by the enactment of

Back 4

the Health Maintenance Organization Act of 1973

Front 5

Kaiser-Permanente

Back 5

Health Insurance Plan which placed considerable emphasis on preventive medicine; exercised control over hospitals by contracting their services; employed mechanisms, such as penalizing physicians, to curtail excessive use of hospital facilities; eventually became the model for HMOs

Front 6

Health Maintenance Organization Act (HMO Act) of 1973

Back 6

objective of stimulating growth of HMOs by providing federal funds for the establishment and expansion of new HMOs

Front 7

reason for supporting the growth of HMOs

Back 7

the belief that prepaid medical care, as an alternative to traditional fee-for-service practice, would stimulate competition among health plans, enhance efficiency, and slow the rate of increase in health care expenditures

Front 8

Uses discounted fee payments instead of capitation

Back 8

Preferred Provider Organizations (PPOs)

Front 9

Methods commonly used for utilization monitoring and control

Back 9

choice restriction, gatekeeping, case management, utilization review, practice profiling

Front 10

Prospective Utilization Review

Back 10

appropriateness of utilization is determined before the care is actually delivered; examples include preauthorization of hospital admission and second opinions for surgical procedures

Front 11

Three categories for the management of utilization

Back 11

prospective, concurrent, and retrospective

Front 12

Concurrent Utilization Review

Back 12

occurs when decisions regarding appropriateness are made during the course of health care utilization; seeks to limit the length of stay; examples include monitoring the length of inpatient stays and discharge planning

Front 13

Retrospective Utilization Review

Back 13

managing utilization after services have already been delivered; based on an examination of medical records to assess the appropriateness of care; ex. large claims being reviewed for billing accuracy; practice profiling may be a byproduct