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9 Cards in this Set
- Front
- Back
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Objectives of Managed Care
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Control the growth of health care expenditures by managing utilization of services and reimbursement to providers
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Provider Payment Arrangements
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Citation (Per Member Per Month), provider fixed monthly amount PMPM; Discounted Fees
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Utlization Control Measures
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Determination of medical necessity, determination of most cost-effective method delivery, review treatment, two types (gatekeeping and utilization review)
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Gate Keeping
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PCP coordinates care; in early days PCP reduced income if had too many referrals
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Utilization Review - Prospective
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Is there a medical necessity? Main objective is to prevent unnecessary or inappropriate institutionalization or treatments
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Utilization Review - Concurrent
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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)
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Alliance
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An agreement between two or more orgs to share resources
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Virtual Organization
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a new org formed through contractual arrangements between two or more existing orgs; healthcare network is created through contractual agreements, rather than ownership
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Main effects on healthcare by integrations of orgs into health networks
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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.
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