HMOs provide medical care for their patients for a prepaid fee. The paper must include an introduction, a body with fully developed content, a conclusion and a references. In 1980, 236 HMOs served 9 million members. Similar results emerged for the analysis of the relationship between financial incentives and outpatient primary care visits per HMO enrollee: lower rates were found in HMOs that put physicians at risk for deficits in the physician referral and hospital pools and for outpatient diagnostic tests. Cerne F, Traska MR. No individual applying for health coverage through the individual marketplace will be discouraged from applying for benefits, turned down for coverage or charged more premium because of health status, medical condition, mental illness claims experience, medical history, genetic information or health disability. D.conducted by several organizations, some specialize in specific aspects of managed care. HMOs are not a one-size-fits-all policy. [TRUE/FALSE] An IDS may NOT operate primarily as a vehicle for negotiating termswith private payers. He further notes, however, that the reasons for these conversions have changed over time. The many diverse HMO structures and the mixture of these elements of managed care systems make it exceedingly difficult to disentangle the effects of utilization management methods, provider selection, and financial incentives to determine which specific mechanisms are most effective. Consequently, the practice patterns of physicians may make the difference in a prepaid setting between satisfactory financial performance and financial losses. The Staff Model is characterized by HMO ownership of the delivery system facilities and the employment of physicians on salary to serve exclusively the HMO membership. [9]Lastly, staff model HMOs generally employ their providers directly and own the facilities where care is delivered.[9]. GHAA recognizes Mixed Model HMOs but classifies them by the model that serves the largest number of members in the HMO. 4.) Advantages of an IPA include: Even though some limited evidence exists that managed care, particularly HMOs, may have an impact on utilization of services and the overall level of costs, most of this evidence is based on data from older, well-established HMOs that were operating in the 1970s and earlier. What structures and policies generally result in better performance? A health maintenance organization (HMO) is a type of plan that requires members to get care within the plans network of providers. Thus, the impact of capitation on physician decisionmaking may vary significantly depending on the total package of services for which the physician is at risk. Test Bank Exam 1 Principles of Managed Care 012820.docx, Test Bank EXAM 2 Principles of Managed Care.docx, ESSENTIALS OF MANAGED CARE FA16 - SECTION D03 HA3120D, 2 points Key common characteristics of PPOs do NOT include: Limited provider panels O Discounted payment rates Consumer choice O Utilization management Benefits limited to in-network care, 1.) Accountable care organizations (ACOs), including the similar concept of clinically integrated organizations (CIOs), represent one such innovation in the managed care space. The balance budget act of 1997 resulted in a major increase in Medicare HMO enrollment. Langwell et al. Gruber LR, Shadle M, Polich CL. about health plans. True or False 13. Because of their financial arrangements with providers, IPA Model HMOs were found to have a higher level of data availability, overall, than were other HMOs. True The following term refers to an all-inclusive rate paid by the HMO for both institutional and professional services: Bundled payment Behavioral change tools include all but which of the following? When to reject the health insurance plan at work, How to get your health insurer to pay for your weight-loss or bariatric surgery, A complete guide to short-term health insurance, Do Not Sell or Share My Personal Information, No, but out-of-network usually costs more. 28. Hillman AL, et al. Correct Response: Elizabeth Rivelli is a freelance writer who covers various insurance topics. Recent reviews have discussed the likelihood that human milk oligosaccharides can function to protect the infant from pathogenic organisms. HMOs in which physicians serve only prepaid patients. One of the major characteristics of managed care plans that differentiates them from traditional expense plans is: D. Managed care plans limit the choice of medical care providers that may be used. If you were to apply their views to your. A principal characteristic of HMO organizations is the provision of managed care services to enrolled populations. Concurrent utilization review (51 percent). Physician practice profiles (23 percent). In addition, PPOs recruit and offer a network of preferred providers who are selected on the basis of practice style and willingness to follow the utilization management and review requirements of PPOs. A. direct access to specialists B. any-willing-provider laws C. provider gag clauses D.Point-of-service options, Which of the following statements concerning accreditation of managed care plans is incorrect? (1989) use data from a survey of 283 HMOs to examine the relationship between financial incentives and hospitalization rates of HMO members and other measures of HMO performance. The Medicare risk HMOs were less likely to report using primary care gatekeepers (81 percent versus 93 percent of GHAA respondents) and retrospective inpatient review (56 percent versus 89 percent of GHAA respondents) and were more likely to report using physician practice profiles as a management tool (59 percent versus 44 percent of GHAA respondents). If, for example, Medicare risk contracting HMOs are losing money only on their Medicare line of business, then this fact may suggest a problem with the terms of the risk contract arrangements. the contents by NLM or the National Institutes of Health. [17]Additionally, pharmacies have attempted to control costs without compromising care by using techniques such as drug formularies and prescribing protocols. HMOs aredesigned to accomplish these goals by integrating health insurance and health care delivery within the same organization and thus aligning the incentives of the health care payer and provider. Gatekeeping and patterns of outpatient care post healthcare reform. HHS Vulnerability Disclosure, Help An HMO is a health insurance plan that contracts with a provider network of specific doctors, hospitals, and other medical professionals. 61 percent capitated primary care physicians. The result of these trends is that for-profit HMOs are now the majority in the industry. A positive relationship between chain affiliation and performance may be expected because of the affiliated HMO's greater access to capital for expansion. GHAA (1988) reports that among all HMOs that responded to their 1987 annual survey, the distribution of utilization management activities included: By contrast, Langwell, Carlton, and Swearingen (1989) report that PPOs responding to a survey of interest in Medicare contracting indicated that PPO utilization management activities included: A recent study by Nelson et al. Mixed Model HMOs have developed in response to the desires of Staff and Group Model HMOs to expand their market areas without using substantial capital investment to build or purchase new facilities. HMOs are a type of managed care designed to maintain the health of their patients cost-effectively. Others pay a greater share of costs for providers outside the plans network. Usually, HMO's have all of the following characteristics EXCEPT: B. fee for service system of care = this is not true, Which of the following is a characteristic that distinguishes an HMO from an insurance company? Roemer MI, Shonick W. HMO performance: the recent evidence. Covered employees have financial incentives to receive treatment with in the preferred provider network. That means you have to get your primary care physicians OK before seeing a specialist. Staff Model HMOs were most likely to have added a Mixed Model component, with 63 percent reporting this change. The role of the MIS in generating ongoing utilization reports by patient, physician specialty, service, procedure, and individual physician is particularly essential. By charging patients per provider visit, cost-sharing strategies seek to disincentivize the overuse of medical services that might occur if patients were not responsible for any per-visit costs. Consequently, understanding the nature of the organizational structure of the HMO through classification into models can provide valuable information on the expected performance of the HMO. C. Disease management programs typically focus on a single episode of impatient care. The referral responsibility creates additional work for primary care providers as well, Decker says. GHAA (1989) reports that even though 72 percent of respondent HMOs with over 3 years experience were federally qualified, only 44 percent of HMOs that had been operational for less than 3 years reported Federal qualification. In the early 1970s, HMOs were classified into three types: Staff, Group, and IPA. Find out if you qualify for a Special Enrollment Period. Chain-affiliated HMOs were more likely than were independent HMOs to use each of the utilization control methods. She has also written for several insurance carriers. IPA Model HMOs were more likely to report using gatekeepers, to require prior authorization for hospitalization, and to use physician practice profiles. By the mid-1980s, however, the limitations of competitive flexibility imposed by community rating requirements and mandatory benefit packages may have offset the advantages of the Federal seal of approval in negotiating contracts with employers. Management information systems for the fee-for-service/prepaid medical group. How do I sign up for Medicare when I turn 65? The Nelson et al. [11]ACOs were authorized in the 2010 Affordable Care Act (ACA), and like HMOs, were introduced to provide quality, cost-efficient care. Managed care plan performance since 1980. HMOs are increasingly being recognized for their importance for infant health and development. 3.) Unlike other health insurance plans, HMOs typically require the member choose a primary care physician (PCP), who is responsible for coordinating their care. 22. The study was not able, however, to take into account a number of factors that may be expected to influence both the rate of service use and overall financial performance of the HMO. Houck and Mueller (1988) suggest that the historical prevalence of nonprofit HMOs was attributable to legal prohibitions against the corporate practice of medicine and the availability of Federal grants and loans only to nonprofit HMOs.
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