MCO
Managed care organizations
-assume (some) financial risk for expenditures
and have incentives to control costs and utilization of health services
Ex: Kaiser Permanente
Health Maintenance Organization Act of 1973
required employers with more than 25 employees that offered a health plan to also offer an HMO-type alternative to an indemnity plan
Capitation
Pays providers on a pre-determined basis
- If the providers can treat the patient for less: they can keep the rest of the $$$
- If the providers cannot treat the patient for less: they must absorb the costs $$$
is a fixed amount of money per patient per unit of time paid in advance to the physician for the delivery of health care services
Risk is
the chances for financial losses
Who’s at risk for fee-for service
Full risk for Insurer for MD and hospital
Full Capitation
Providers are paid a predicted cost of care for a given population for a specified time (1 yr).
- Obligated to provide all needed care for that population
Risk pools
- A portion of payment (a “withhold”) placed in a pool to cover claims that exceed projections
- Physician and HMO share any surplus or loss at end of year
Gatekeeper
A primary-care physician must coordinate & authorize all medical services to be covered
- Financially at risk so as to minimize unnecessary services
Network
HMO’s generally do not provide coverage for care that is received out of network
Four Types of HMOs
- Staff-Model
- Group-model
- Network-model
- Independent practice association (IPA) model
Staff-Model
HMO directly owns all facilities and providers are employees.
• Physicians bear no direct risk, but salaries based on company performance
- subject to utilization review; therefore may influence care
Group-model
HMO contracts with large, multi-specialty medical groups offering services exclusively to the HMO.
- Capitated
Network-model
Nonexclusive contracts with large medical groups.
- Physicians bear risk, but reduced influence by HMO
Independent practice association (IPA) model
Physicians form a separate legal entity that contracts with MCO;
- the IPA shares risk with MCO.
- IPA contracts with physicians on a discounted FFS basis.
- Contracted physicians usually have their own practices and can provide services to other patients and other MCOs
Characteristics that Differentiate MCO Types:
Health Maintenance Organization
Physicians are hired
No Out-of-Network Care
Primary Care Physician
Characteristics that Differentiate MCO Types:
Preferred Provide Organization
Physicians are contracted
Out-Of-Network care
Characteristics that Differentiate MCO Types:
Exclusive Provider Organization
Physicians are contracted
No Out-of-Network care
Characteristics that Differentiate MCO Types:
Point-of-Service
Physicians are contracted
Out-of-Network Care
Primary care physicians
Whats the differnce between FFS plans and Managed care
The use of provider networks
Provider network
is a group of providers contracted to supply a full range of primary and acute health care services (and share risk
Four characteristics that differentiate types of MCOs
- Risk-bearing
- Physician type
- Relationship exclusivity
- Out-of-network coverage
Risk-bearing
the amount of risk borne by the provider, which can range
from full risk to no risk.
Physician type is the
relationship between the MCO and the physician(s)
Relationship exclusivity
whether the physician provides care to patients
from one MCO only or to patients from multiple MCOs
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Lecture 1-393
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Lecture 4-789
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Lecture 944
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Lecture 1055
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Lecture 11 and 12: Medicare and Medicaid40
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Lecture 13: Health Care Reform36
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Lecture 14: Drug Development and Biosimilars45
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Lecture 15: Intro to Pharmacoepidemiology and Drug Safety48
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Lecture 16: Intro to Pharmacoeconomics32
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Exam 2 Practice Questions12
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Lecture 19: Pharmacy Practice Settings6
