Care Delivery Methods

Question 1

HMO

Answer 1

• Provides for or arranges for coverage of designated health services for a fixed prepaid premium.
• Provider’s receive a predetermined payment per member per month.
• PCP is the gatekeeper.
• Access through specialists through PCP and limited to that which is necessary for the patient’s condition.
• Out of Network coverage is very limited

Question 2

PPO

Answer 2

• Insurance which contracts are established with providers of care (preferred providers).
• Contract provides better benefits when preferred providers are used as an encouragement for members to use them.
• Can use out of network providers with higher out of pocket costs.

Question 3

Point of Service (POS)

Answer 3

• Allows for blend of HMO and PPO
• Allows members to choose between participating and non-participating providers.
• Members usually pay substantially higher costs in terms of increased premiums, deductibles, and coinsurance.

Question 4

Integrated Delivery System (IDS)

Answer 4

• Partnerships between physicians, physician groups, hospitals and other providers to manage care.
• Usually involves contact with payer and provides services across the continuum.
• May become Accountable Care Organization
• Increasingly popular today - most common with academic medical centers.

Question 5

Accountable Care Organization (ACO)

Answer 5

• Came from the ACA under the CMS Center for Innovation.
• Main purpose is to improve beneficiary outcomes and increase value of care by providing better care for individuals, better health for populations and reducing growth in expenditures.
• The **goal **is to deliver high quality coordinated care to MEDICARE BENIFICIARIES especially those with chronic illnesses so they can access the right care at the right time, avoiding unnecessary duplication of services and preventing medical errors.

Question 6

Accountable Care Organization (ACO)

Answer 6

• Participation is voluntary.
• These groups of physicians, hospitals and other health care providers are expected to provide coordinated, high-quality care.
• The providers are held jointly accountable to deliver care more efficiently, achieve measured quality improvements, and reduce the rate of spending growth. AND they are incentivized to acheive these quality measures.
• Patients are free to select which services they receive and from whom.
• 33 measures and 4 domains (patient/CG experience, care coordination and patient safety, preventative health, and at-risk populations).

Question 7

Core Components of ACO

Answer 7

Provider led, strong base in primary care, all providers are accountable for quality and cost, payments linked to improvements that reduce cost and performance is measured.

Question 8

Individual Practice Association (IPA) Model

Answer 8

An HMO model that contracts with a private practice physician or healthcare association to provide healthcare services in return for a negotiated fee. The IPA then contracts with physicians who continue in their existing individual or group practice. (Private practices accepts HMO’s)

Question 9

Staff Model HMO

Answer 9

Physicians are employed by the HMO to provide care exclusively to health plan enrollees.

Question 10

Network Model HMO

Answer 10

Fastest growing form of managed care. Contracts with variety of groups of physicians and other providers in a Network of care with organized referral patterns. Networks allow providers to practice outside the HMO.

Question 11

Exclusive Provider Network (EPO)

Answer 11

Patient’s are not reimbursed for out-of-network care.