Ma. Lorena D.

Lorenzo, MD, FPAFP

 Learning Objectives
–
§ Define managed care
§ Discuss the demand for health care
§ Differentiate traditional health insurance
from managed care insurance
§ Enumerate the different types of managed
care organizations
 Define Managed Care
–
is a medical care that is
provided by a corporation
established under state
and federal laws.

The term “managed care”

is often used to describe
certain medical plans.
http://evolve.elsevier.com/Beik/today/
 Define Managed Care
–
- a generic term for various health
care payment systems that attempt
to contain costs by controlling the
type and level of services provided

http://www.encyclopedia.com/topic/managed_health_care.aspx
 Define Managed Care
–
- a complex healthcare system in which
physicians, hospitals, and other
healthcare professionals organize an
interrelated system of people and
facilities that communicate with one
another and work together as a unit,
commonly referred to as a network.

http://evolve.elsevier.com/Beik/today/
 Managed care provider
–
§ tells patients which physician they can
see
§ monitors the medications and
treatments prescribed
§ ensures enrollees that their costs will
remain as low as possible.
 Enrollees
–
§ pay a set insurance premium
each year and a small
copayment with each visit
Is HMO the same as Managed Care?
–
The Demand for Health Care
–
Universal health coverage aims to
ensure that all people obtain the health
services they need without suffering
financial hardship when paying for
them.
The Demand for Health Care
–

The cost of healthcare is increasing rapidly.

2 Broad Categories of Insurance
–
1. FFS plan

2. Managed care plan

 4 Basic Types of Plans
–
1. Traditional FFS/Indemnity Plans
2. Preferred provider organizations
(PPOs)
3. Point-of-service (POS) plans
4. Health maintenance organizations
(HMOs)
Types of Managed Care Plan
–
1. Preferred provider organizations
(PPOs)

2. Point-of-service (POS) plans

3. Health maintenance organizations

(HMOs)
Traditional Health Insurance vs.
Managed Care Insurance
–
Fee-for-service (FFS)
(indemnity) insurance

§ a traditional type of healthcare

policy where the insurance
company pays fees for the
services provided to individuals
covered by the policy.
Traditional Health Insurance vs.
Managed Care Insurance
–
FFS
§ can cover everything but the tradeoff is the
cost

§ there is autonomy or freedom to choose

what medical expenses will be covered
§ offers unlimited choices
§ with flexible coverage
Traditional Health Insurance vs.
Managed Care Insurance
–
FFS
§ often, they do not cover preventive
medicine
§ impractical for a large family that
requires many routine visits and
preventive care
§ choice does not come cheap.
Traditional Health Insurance vs.
Managed Care Insurance
–
FFS
§ becoming less popular as managed
care moves to the forefront in
healthcare
Traditional Health Insurance vs.
Managed Care Insurance
–
Few costs that are standard, under FFS:
1. A periodic payment (monthly or
quarterly) health insurance
policy premium
2. A yearly deductible (out-of-pocket
payment) before the health insurance
carrier begins to contribute
3. A per-visit coinsurance, or percentage of
healthcare expenses
Traditional Health Insurance vs.
Managed Care Insurance
–
FFS
As a rule, healthcare services that are
not covered by the health insurance
policy (like check-ups) do not count to
satisfying the deductible.

Cost of FFS = varies with the level of

coverage chosen
Traditional Health Insurance vs.
Managed Care Insurance
–
All FFS health plans are not created
equal. The 3 levels of coverage:
1. Basic Health Insurance
2. Major medical insurance
3. Comprehensive insurance
Traditional Health Insurance vs.
Managed Care Insurance
–
1. Basic Health Insurance
§ Hospital room and board and
inpatient hospital care
§ Some hospital services and supplies,
such as x-rays and medicine
§ Surgery, whether performed in or out
of the hospital
§ Some physicians visits
Traditional Health Insurance vs.
Managed Care Insurance
–
2. Major medical insurance
§ Treatment for long, high-cost
illnesses or injuries
§ Inpatient and out-patient expenses
3. Comprehensive insurance
§ Combination of the two
Traditional Health Insurance vs.
Managed Care Insurance
–
Health Maintenance Organizations (HMOs)

§ receive most or all of health care from a

network provider
§ require that you choose a primary care
physician (for managing and coordinating
all of your health care)
Traditional Health Insurance vs.
Managed Care Insurance
–
Health Maintenance Organizations (HMOs)

If you need care from a physician specialist in

the network or a diagnostic service such as a
lab test or x-ray, your primary care physician
(PCP) will have to provide you with a referral.
Traditional Health Insurance vs.
Managed Care Insurance
–
Preferred Provider Organizations (PPOs)
§ a health plan that has contracts with a
network of "preferred" providers from
which you can choose.
§ You do not need to select a PCP and you
do not need referrals to see other providers
in the network.
Traditional Health Insurance vs.
Managed Care Insurance
–
Preferred Provider Organizations (PPOs)
§ If you receive your care from a doctor in
the preferred network you will only be
responsible for your annual deductable
and a copayment for your visit.
Traditional Health Insurance vs.
Managed Care Insurance
–
Preferred Provider Organizations (PPOs)
§ If you get health services from a doctor
or hospital that is not in the preferred
network, you will pay a higher amount
- perhaps a coinsurance of 20% or
more. And, you will need to pay the
doctor directly and file a claim with the
PPO to get reimbursed.
Traditional Health Insurance vs.
Managed Care Insurance
–
Point-of-Service (POS)

§ plan that is a combination of a health

maintenance organization and a preferred
provider organization.
§ have a network that functions like a HMO
– you pick a primary care doctor
Traditional Health Insurance vs.
Managed Care Insurance
–
Point-of-Service (POS)
§ also allow you to use a provider who is
not in the network.

§ you can decide to stay in the network

and allow your PCP to manage your
care or go outside the network on your
own without a referral from your PCP.
 Management Strategies Facing
Consumers/Patients and Health Care
Providers
–
Utilization review, sometimes referred to
as utilization management, is a system
designed to determine the medical
necessity and appropriateness of a
requested medical service, procedure, or
hospital admission prior, concurrent, or
retrospective to the event
 Complaint Management
–
If a particular medical service or
procedure is determined not to be
medically necessary by the payer, it is not
paid for by the insurer. If the patient
disagrees, he may file a grievance
protesting the decision.
 Regulation of MCOs
–
Preauthorization
§ procedure required by most managed
healthcare and indemnity plans before
a provider carries out specific
procedures or treatments for a patient
– typically inpatient hospitalization
and certain diagnostic tests
 Regulation of MCOs
–
Precertification
§ process used by health insurance
companies to control healthcare costs;
a formal assessment of medical
necessity, efficiency, or
appropriateness of a medical
provider’s treatment plan for a
specific illness or injury
 Regulation of MCOs
–
Predetermination

§ when the provider notifies the

insurance company of the
recommended treatment before it
begins.
 Regulation of MCOs
–
Referral
§ request by a healthcare provider for a
patient under his care to be evaluated
or treated by another provider
Philippine Health Insurance
–
THE call to serve the rural indigents
echoed since the early '60s when the
Philippine Medical Association
introduced the MARIA Project which
prioritized aid to communities in need of
medical assistance.
Philippine Health Insurance

August 4, 1969
–
§ Republic Act 6111 or the Philippine
Medical Care Act of 1969 was signed
by President Ferdinand E. Marcos
which was eventually implemented
in August 1971.
§ The Philippine Medical Care
Commission (PMCC) was tasked to
oversee the implementation
 Philippine Health Insurance
–
1990s
§ development of House Bill 14225 and
Senate Bill 01738 which became The
National Health Insurance Act of 1995
or Republic Act 7875, signed by
President Fidel V. Ramos on February 14,
1995.
 Philippine Health Insurance
–
§ The law paved the way for the creation
of the Philippine Health Insurance
Corporation (PhilHealth), mandated to
provide social health insurance
coverage to all Filipinos in 15 years'
time.
 OTHER TOPICS
–

REVIEW PAST TOPICS IN FAMILY MEDICINE

 VALIDITY STUDIES
–
Face validity - confirmation from a group of experts or other
stakeholders as to whether this tool appears to be a
reasonable measure of the concept as they understand it

Content validity - checks whether all the item in the tool that
should be included are included and identifies the relevance
of each indicator and criterion; attained through asking
experts whether or not the tool appears to contain all the
important concepts, behaviors, and elements of the concept;
it can be more formally assessed by observing patients to see
behaviors (interview them or review records) or base the tool
on previously reported measures
 VALIDITY STUDIES
–
Construct validity = is the extent to which the items in
the tool are as closely associated as expected, according
to theory

Criterion-related validity = determines the ability of each

criterion of the tool to measure accurately a specific
concept or condition. To assess this ability, the criterion is
compared with a "gold", or reference standard. This is the
STRONGEST FORM OF VALIDITY.
EVIDENCE BASED MEDICINE
–
 STEPS IN THE EBM PROCESS
The patient
–
1. Start with the patient – a clinical problem or question
arises out of the care of the patient

The question 2. Construct a well built clincial question from the case

The resource 3. Select the appropriate resource(s) and conduct the search

The evaluation 4. Appraise the evidence for its validity and applicability

The patient 5. Return to the patient – intergrate the evidence with the
clinical expertise, patient preference and apply it to practice

Self evaluation 6. Evaluate your performance with this patient

DECISION ANALYSIS LINE
–
 DECISION ANALYSIS LINE
–
™ Diagnostic Threshold (DT): arbitrary point at which you
rule out the disease below this point
– After this point, you will request for a diagnostic test
™ Therapeutic Threshold: arbitrary point at which you
decide to treat beyond this point
– Below this point, you will request for a diagnostic test
™ Pre-Test Probability: probability that the patient has the
disease
™ Post-Test probability: probability that the patient has the
disease after doing the diagnostic exam
–
 LIKELIHOOD RATIO
–
™ Likelihood ratio of a positive test
– Probability that the test is + among diseased person
Probability that the test is + among non-diseased person
– LR (+) = Sensitivity/1-Specificity

™ Likelihood ratio of a negative test

– Probability that the test is - among diseased person
Probability that the test is - among non-diseased person
– LR (-) = 1-Sensitivity/Specificity
–
–
 EBM
–
™ Look at the abstract or methodology.

– SINGLE blinding?
– DOUBLE blinding?
– TRIPLE blinding?
 TREATMENT EFFECT
–
RISK IN TREATMENT (Rt)

No. of patients who did not get well in the treatment group
Total no. of patients in the treatment group

RISK IN CONTROL (Rc)

No. of patients who did not get well in the control group
Total no. of patients in the control group
 RISK REDUCTION
–
™ Absolute Risk Reduction (ARR) = Rc – Rt

™ Relative Risk (RR) = Rt/Rc

RR of 1 : No difference between Treatment and Control

RR of >1: Treatment is more harmful
RR of <1: Treatment is more effective

™ Relative Risk Reduction (RRR) = 1 – RR

 CEA
–
™ Catharsis Education and Action

™ Counseling technique that takes on many features of Carl

Roger’s person-centered psychotherapy

™ Brings out the psychological concerns that result from

wrong perception of reality and hinder appropriate
behavior
 CEA
–
™ Catharsis phase – clarify or define problem
- hidden emotions surface and ventilated so that they
will not disturb the analytical functions of the mind
- looking at barriers and enablers in treatment
- utilization of active listening skills

™ Education – interactive case analysis and use of two-way

communication for scientific evidence

™ Action – plan implementation