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9 Cards in this Set

  • Front
  • Back
Objectives of Managed Care
Control the growth of health care expenditures by managing utilization of services and reimbursement to providers
Provider Payment Arrangements
Citation (Per Member Per Month), provider fixed monthly amount PMPM; Discounted Fees
Utlization Control Measures
Determination of medical necessity, determination of most cost-effective method delivery, review treatment, two types (gatekeeping and utilization review)
Gate Keeping
PCP coordinates care; in early days PCP reduced income if had too many referrals
Utilization Review - Prospective
Is there a medical necessity? Main objective is to prevent unnecessary or inappropriate institutionalization or treatments
Utilization Review - Concurrent
Care is reviewed for appropriateness during the course of treatment (monitoring length of patient stay, preapproved number of days, trained nurse review and decision to authorize or deny additional days)
An agreement between two or more orgs to share resources
Virtual Organization
a new org formed through contractual arrangements between two or more existing orgs; healthcare network is created through contractual agreements, rather than ownership
Main effects on healthcare by integrations of orgs into health networks
enabled hospitals to expand into new markets and provide full array of healthcare services; increased competition; generally operate more efficiently than independent orgs, though complex and difficult to manage.