Sn 601-05 Chpt 2 Organizational Considerations For Hmo's

Front 1

How a Capitated Medical Group Evaluates its Success

Back 1

 Compute revenue they would have earned under a Ffs system
 Compare this with the capitation income.

Front 2

Practice Management: Ways Providers can Manage and Reduce their Capitation Risk (Prepaid Risk)

Back 2

 Control Utilization
 Control referral costs
 Transfer Risk

Front 3

 Control Utilization

Back 3

 Minimize emergency room use by having expanded clinic hours
 Perform outpatient instead of inpatient
 Avoid duplication of tests
 Use prospective, concurrent, and retrospective UR
 Develop an information system
 track each physician’s performance, cost, etc.

Front 4

 Control referral costs

Back 4

 Refer patients to the most cost-effective hospital
 negotiate discounted fees with the referral physicians
 purchase specialist time (“on a retainer basis”).
 ban secondary referrals
 Only use referrals for specified diagnoses.
 add specialists to the staff.

Front 5

 Transfer Risk

Back 5

 Purchase stop-loss
 Subcontract with umbrella groups for more capital
 use risk-sharing with the HMO