MHA500 Discussion, paper and powerpoint

Module 3 - Home

MANAGED CARE, ACCOUNTABLE CARE ORGANIZATIONS, HEALTH CARE CONSUMER PLANS/MODELS

Modular Learning Outcomes

Upon successful completion of this module, the student will be able to satisfy the following outcomes:

· Case

· Evaluate and describe key features of CDHPs, MCOs, HMOs, PPOs, POSs, and ACOs.

· SLP

· Distinguish characteristics for successful business operations/administrations and apply appropriate health care models.

· Discussion

· Assess a health insurance plan and propose recommendations for improvement.

Module Overview

Managed Care Organization (MCOs)

An MCO is a type of health care system that links health insurance with care delivery for a defined population. An MCO delivers health care through a network of providers, determines the prices for services, coordinates care, and manages appropriate use of health care services. One of the goals of the MCO is to provide the highest quality of care within the limits of available resources.

Health Maintenance Organization (HMO) — Closed Panel HMO

· Key features:

· Contract with physicians and physician groups on an exclusive basis.

· Physicians do not see patients from other HMOs.

· Patients need to select a PCP and require a referral for specialty care.

· Highest restriction for access. No payment for outside network providers if services are rendered outside of HMO network.

· Two Types:

· Staff Model:

· Physicians are salaried employees of HMO.

· HMO owns hospitals and other health care facilities.

· Hospitals and facilities open to HMO members only (in principle).

· Group Model:

· Contracts with a single medical group for services.

· Physicians employed by the medical group, not the HMO.

· The medical group practices with the HMO only.

Health Maintenance Organization (HMO) — Open Panel HMO

· Key features:

· Contracts with independent physicians.

· Physicians see patients in the physician's own office.

· Physicians can see patients from other HMO’s.

· Patients need to select a PCP and require a referral for specialty care.

· Two types:

· Network Model:

· Contracts with multiple medical groups or independent delivery network (IDN).

· IPA Model

· Contracts with an independent physician or physician associations.

· Providers paid on a discounted fee schedule or capitation.

· High volume of patients.

Preferred Provider Organization (PPO)

· Key features:

· Contracts with independent physicians and hospitals as "preferred" network.

· Physicians see patients in the physician's own office and are paid with a negotiated fee.

· Patients do not need a PCP and no referral is needed for specialty care.

· The least restrictive MCO plan.

Point of Service (POS)

· Key features:

· Between HMO and PPO.

· Members need a PCP and referral for specialty care with HMO benefits.

· Members can go outside of network for services (with a higher deductible and co-payments).

ACOs

According to the National Accountable Care Organization Summit (n.d.), ACOs are provider collaborations that support the integration of groups of physicians, hospitals, and other providers in different ways around the opportunity to receive additional payments by achieving continually advancing patient-focused quality targets and demonstrating real reductions in overall spending growth for their defined patient population. The ACO model is highly flexible and can be organized in several ways—ranging from fully integrated delivery systems to networked models within which physicians in small office practices can work effectively together to improve quality, coordinate care, and reduce costs. According to Shortell, Casalino, and Fisher (2010), there are at least five different types of practice arrangements that could serve as ACOs:

1. integrated or organized delivery system

2. multispecialty group practices

3. physician-hospital organizations

4. independent practice associations

5. “virtual” physician organizations,

Burton, D. (2014). What Is an ACO? Definitive Guide: Accountable Care Organizations. Retrieved from  www.healthcatalyst.com/what-is-an-ACO-definitive-guide-accountable-care-organizations.

National Accountable Care Organization Summit. (n.d.). What is an ACO? Retrieved from  http://www.acosummit.com/past2011/overview.html

Shortell, S. M., Casalino, L. P. & Fisher. E. S. (2010). How the Center for Medicare and Medicaid Innovation should test Accountable Care Organizations. Health Affairs, 29 (7), 1293-1298.