Chapter 27 - Managed Care

Question 1

Definition of managed care:

Answer 1

Term given to a process whereby an insurer intervenes in the provision of medical care with the dual objective of optimising the quality of treatment for the PH and controlling the cost to maintain the affordability of HC by such means as preferred provider utilisation and claims pre authorisation

Question 2

What is the main objectives of managed care interventions? (5)

Answer 2

1. Reducing cost of medical events
2. Improving quality of care provided
3. Ensuring that medical services are delivered on an appropriate setting
4. Ensuring that high risk memebers are managed and receive appropriate care
5. Reducing the number of unnecessary medical services

Question 3

Risks transferred from insurer to manage care organisation: (4)

Answer 3

1. Price risk - relates toncost of treatment
2. Frequency risk - relayes to number of times PH needs treatment
3. Intensity/severity risk - refers to how resource intensive the treatment is
4. Profile risk - relates to mix of lives covered with and without disease