IPP Exam 2 - Managed Care

What is managed care

• any movement away from direct payment or "fee for service" as a means to control cost
• a system of regulations or restrictions placed upon the utilization of health care resources
• a physician is in charge of managing all care related to you
• a pharmacist who oversees all the charts from physicians to ensure adequate care from all healthcare providers

What is a fee for service (FFS)

• insruance pays what the provider bills, no limits
• insurance pays what the provider bills until a limit is reached
• insurance & provider negotiate the reimbursement, but no real limits on quantity of use
• insurance & provider negotiate the reimbursement but there is a limit on how much they can use

What types of regulations and restrictions might be placed upon utilization of health care resources

• cost control
• time control
• quality control
• product control

Why can it be said that the healthcare system behaves like a monopoly instead of a market

• Competition is hard
• Competition is based on non-price factors
• Competition is based solely on price factors

Where did managed care come from and how did the American Medical Association react

• fraternal lodges and immigrant societies in 1800s
• previous physician practices in the 1800s
• initially poorly received by AMA
• initially wonderfully received by AMA

How did World War II affect managed care

• decreased the success of managed care
• brought expansion to managed care

During World War II, what groups helped to expand managed care

• Group Health Cooperative of Puget Sound
• Health Maintenance Organization
• Kaiser Permanente

The Health Maintenance Organization Act (1973) helped to

• create start-up grants & loans to form HMOs

• required companies with 25 or more employees to offer HMO option

• allowed for growth of HMOs

• required all companies to offer HMO option

What are some basic cost control principles

• evidence-based medicing
• typical treatment methodologies (standard of care)
• contract specifics with health care providers
• individual patient needs
• cost containment strategies

What are the basic theories behind healthcare plans

• risk bearing
• physician type
• relationship exclusivity
• out of network coverage