Professional Documents
Culture Documents
Lva1 App6891
Lva1 App6891
HEALTHCARE
DELIVERY AND
FINANCING IN THE
HMO ACT OF 1973
Federal qualification requirements
Consumer expectations
Technological factors
COST SHIFTING
Antiselection
Deductible
Coinsurance
Pre-existing condition
Cost (1-5) 5 is 5 1 4 3
max
Freedom (1-5) 5 1 4 3
5 is max.
Key Players in Managed Care
Providers
Payers
Purchasers
Members
Utilization Management
Demand Management
Utilization Review
Disease management
FFS SALARY
🢝 Capitation PER DIEM
COA
Membership
Membership-> Individually or
Group
Under group plan -> no contractual
relationship with HP
Open Enrollment period
Delivery of Healthcare is primarily
Comprehensive Care
Basic medical Services + offer
extensive preventive care
programs. Prenatal care, well-
baby care, routine physical
examinations, 24-hour telephone
line access to a nurse, and
Networks
Parameters in building a network
🢝Access
🢝Credentialing
🢝Contractual relationship
Factors to determine no of primary care and
specialist in a given area
🢝size and location of the geographic service
area
🢝network adequacy
🢝medical needs of its members
🢝employer or other purchaser requirements,
including provider education, board
Before an HMO contracts with a
physician, the HMO first verifies the
physician’s credentials. Upon becoming
part of the HMO’s organized system of
healthcare, the physician is subject to
recredentialing and ongoing peer review.
Requirements for a Hospital
🢝Accreditation from JCAHO
🢝State license
Ancillary Services
Financing in HMO
Prepaid Care
Negotiated
provider compensation
Stop loss provision- capitation- FFS
beyond a certain point
Capitation -> discrete ancillary
Types of HMO Models
Closed panel HMO X Closed access
Closed panel
Compensation->Salary
Group Model
Capitation
Network Model
Specialty services are healthcare services that are generally considered outside
standard medical-surgical services because of the specialized knowledge required for
service delivery and management.
Workers’ compensation
Rehabilitation services
Home healthcare
Cardiac surgery
Oncology services
🢝Inappropriate utilization
Specialty HMO
DHMO
DPPO
DPOS
BEHAVIORAL HEALTHCARE
Factors that fueled growth for
behavioral healthcare
🢝Greater awareness and acceptance
of behavioral healthcare issues
🢝Increased stress on individuals and
families
🢝Increasing availability of services
MBHO is an organization that provides behavioral healthcare
services by implementing health plan techniques
MBHO’s use four different strategies to mange delivery of
services
🢝alternative treatment levels
🢝alternative treatment settings
🢝alternative treatment methods-> drug therapy, psycho
therapy, counseling
🢝 crisis intervention
Directing patients to appropriate care
🢝 PCP
🢝 Centralized Referral System
Pharmacy Benefits plan
Type of managed care specialty service
that seeks to contain the costs of
prescription drugs or pharmaceuticals
while promoting more efficient and safer
drug use
1. Services offered by PBMS
2. Physician Profiling
Formulary management:-is a listing of
drugs, classified by therapeutic category
or disease class
1. Open Formulary
2.Closed Formulary
Structural Integration
Operational Integration
Structural Integration
🢝 Common ownership and Control (Mergers. JVs,
Acquisition)
Operational Integration
🢝Business Integration – Combine one or more separate
business function
Advantages of Integration
Provider Integration Models
Physician Only model
🢝IPAs (Least Integrated)
🢝Group Practices without Walls GPWW/
Management Services Org (MSO)
🢝Physician Practice Management (PPM)
company
🢝Consolidated Medical Group
Physician and Hospital model
🢝Physician Hospital Organization
🢝Integrated Delivery Systems (IDS)
/Medical Foundation (Most
integrated)
Health Systems
Management
Health Plan , Structure
🢝 Sole proprietership
🢝 Partnership
🢝 Corporation
Parent Company
Holding company
Stock/Mutual
Organizational Structure
Inside Director
Outside Director
Responsibilities
🢝 Authorization of major financial transactions, including
mergers, acquisitions, and capital expenditures
🢝 Appointment and evaluation of senior management, including
the organization’s chief executive officer
🢝 Participation in corporate strategic planning
🢝 Approval and evaluation of the organization’s operational policies and
procedures
🢝 Oversight of the plan’s quality management (QM) program, including
Medical Director
🢝 Physician executive who is responsible for the quality and cost-
effectiveness of the medical care delivered by the plan’s providers.
Ad Hoc Committees
🢝 special committees, are convened to address specific management
concerns. Ad hoc committees are typically disbanded once the issue
has been resolved. For example, a special litigation committee may
Network Structure and Management
Market Analysis
🢝 Market Maturity
🢝 Provider Community
🢝 Competitive Landscape
🢝 Economic Conditions
🢝 Characteristics of the Service
Area
🢝 Population Characteristics
🢝 Health Plan Characteristics
🢝 Regulatory requirements
Network Structure and Management
Network Structure
🢝 Open Panel
🢝 Closed Panel
Network Composition
🢝 PCPs
🢝Specialists
🢝 Hospitalists
🢝 Healthcare Facilities
Network Size
🢝 Plan Characteristics
🢝 Population Characteristics
🢝 Plan Goals
Network Structure and Management
Credentialing
🢝 In-house/Third Party Credentialing Agencies
🢝 Providers have to submit forms along with
supporting docs
🢝 Check for licensure, professional liability history,
medical education and training, disciplinary history
🢝 Sources - State Medical Records, Court
Records, National Provider Data Bank (NPDB)
🢝 Upon successful credentialing contract is
negotiated with the provider
Contract Provisions - Provider
🢝Provider Services
🢝Administrative policies
🢝Credentialing and Re credentialing
🢝Participation in UM and QM programs
🢝Maintenance and submission of Medical
records
🢝No balance billing
🢝Requires providers to accept the amount the
plan pays for medical services as payment
in full and not bill plan members for
additional amounts
🢝Hold Harmless provision
🢝Forbids providers from seeking
compensation from patients if HP fails to
Contract Provisions – Health Plan
🢝Payment
🢝Risk Sharing and incentive Programs
🢝Timely Payment
🢝Eligibility Info
Termination provision
🢝Without cause-either the health plan or the
provider may terminate the contract without
providing a reason or offering an appeals
process. The terminating party is often
required to give notice of at least 90 days.
🢝With Cause-permitted by all standard provider
contracts, occurs when one party does not
live up to its contractual obligations, for
example the provider fails to provide required
Cure Provision
🢝which specifies a time period (usually
60–90 days) for the party that breaches
the contract to remedy the problem and
avoid termination of the contract.
🢝due process clause which gives
providers that are terminated
N/W Maintenance and Provider Services
🢝 Orientation
🢝 Peer Review