Post on 22-Dec-2015
HRSA HIV/AIDS Bureau 1
HIV/AIDS BUREAU
HEALTH RESOURCES AND
SERVICES ADMINISTRATION
FUNDAMENTALS OF MANAGED CARE
HRSA HIV/AIDS Bureau 2
FUNDAMENTALS OF MANAGED CARE
1. Managed Care Elements
2. Organizational Models
3. Continuum of Managed Care
4. Functions of MCOs
5. Collaborative Organizations
6. Utilization and Quality Management
7. Information Requirements
HRSA HIV/AIDS Bureau 3
HMOS
PPO PHO
ISN
IPA
TPA
POS
PCCM
IDS
IPO
THE ALPHABET SOUP OF MANAGED
CARE
SSO
MCO
MCP
MCE
HRSA HIV/AIDS Bureau 4
MANAGED CARE ELEMENTS
Combines financing and delivery systems
Patients are enrolled in a managed care plan on a prepaid basis with a defined benefit package that includes preventive and primary care services
Patients select (or assigned) a primary care provider (PCP) who acts as a gatekeeper to coordinate specialty and hospital care
Utilization and clinical practice are reviewed to contain costs while improving health status
Providers typically paid on a capitation basis but can be paid fee-for-service (FFS)
HRSA HIV/AIDS Bureau 5
ORGANIZATIONAL PERSPECTIVE
State (or employer)State (or employer)
Managed Care Organization (MCO)
Managed Care Organization (MCO)
InpatientProviders
InpatientProviders
Primary CareProviders
Primary CareProviders
Specialty/OtherProviders
Specialty/OtherProviders
Premium $$$$
$$$
$$$$ $$$$
State (or employer)State (or employer)
Managed Care Organization (MCO)
Managed Care Organization (MCO)
InpatientProviders
InpatientProviders
Primary CareProviders
Primary CareProviders
Specialty/OtherProviders
Specialty/OtherProviders
HRSA HIV/AIDS Bureau 6
Fee for Service Capitated
More Freedom of Choice Less Choice
More Expensive Less Expensive
INDEMNITY HMOS
Traditional Managed PPO POS IPA/Network Group Staff
THE CONTINUUM OF MANAGED CARE
THE CONTINUUM OF MANAGED CARE
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HMO MODELS
STAFF Physicians are employees of the HMO
GROUP Physicians are members of a multi-specialty or single specialty group practice which in turn contracts with the HMO
IPA Either the individual physician contracts directly with the HMO or the individual physician is part of a physician corporation which contracts with the HMO
NETWORK The HMO contracts with group practices, IPA-physician corporations and/or individual physicians
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OTHER MANAGED CARE MODELS
POINT OF SERVICE (POS) HMO offers members option to receive services from non-
network providers at a reduced level of coverage PREFERRED PROVIDER ORGANIZATION (PPO)
A system which contracts with providers at discounted fees Members may seek care from non-participating providers but at
higher copays or deductibles MANAGED INDEMNITY
Fee for service insurance plan Members receive services from any provider with some
restrictions on utilization and cost e.g. pre-authorization; maximum fee schedule
HRSA HIV/AIDS Bureau 9
FUNCTIONS OF MCOs
MARKETING Private (small, large, federal groups), Individual, Medicaid,
Medicare MEMBERSHIP ACCOUNTING
Group billing and contracts Enrollment & disenrollment; pcp assignment
NETWORK OPERATIONS Provider credentialing and contracting, provider services
MEMBERSHIP SERVICES Inquiries, education, grievances
HRSA HIV/AIDS Bureau 10
FUNCTIONS CONTINUED
CLAIMS ADMINISTRATION In vs Out of Network; physician vs institution Incurred But Not Reported (IBNR) Claims
MANAGEMENT INFORMATION SYSTEMS Reports for all departments
FINANCE budget projections, premium calculations, capitation rates
UTILIZATION MANAGEMENT and QUALITY ASSURANCE
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COLLABORATIVE ORGANIZATIONS
INTEGRATED SERVICE NETWORK (ISN) - a collaboration of either primary care providers (horizontal) or primary, specialty and inpatient providers (vertical) for managed care purposes
PHYSICIAN HOSPITAL ORGANIZATION (PHO) - legal entity between hospital & MDs to contract with MCOs
SHARED SERVICES ORGANIZATION (SSO) - a collaboration between several organizations, such as community health centers, to share administrative, MIS, medical management and other services in order to participate in managed care (also TPA -third party administrators)
HRSA HIV/AIDS Bureau 12
UTILIZATION MANAGEMENT
GOALS plan members receive medically necessary & cost effective
care; utilization and cost patterns of participating providers are within
defined limits; plan meets its utilization and cost projections.
COMPONENTS Referral Process Prior or Pre-authorization: Concurrent Review Formulary Medical Claims Review Physician Selection/Physician Profiling
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QUALITY MANAGEMENT
GOALS Healthcare services are available, accessible & acceptable and meet
defined standards for medically appropriate care Participating providers meet credential criteria Health outcomes monitored & meet established criteria
QUALITY STUDIES Chart Reviews/audits Incident or complaint investigation Specific disease or condition investigation Population wide studies
PROVIDER AND STAFF EDUCATION
PATIENT SATISFACTION SURVEYS
ACCESS STANDARDS REVIEW
HRSA HIV/AIDS Bureau 14
NATIONAL COMMITTEE FOR QUALITY ASSURANCE (NCQA)
Private, not for profit organization; goal is to assess & report on quality of MCP
Two Major Activities: Accreditation and HEDIS
Accreditation: Evaluates how well a MCP manages its delivery system Reviews quality improvement, physician credentialing,
member’s rights & responsibilities; preventive health services; utilization management and medical records
Becoming a Standard - many plans are seeking NCQA credentialling and growing list of employers require it
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HEDIS
Health Plan Employer Data & Information Set Current version is 3.0 which includes commercial
Medicaid & Medicare sectors Key Performance Measures - clinical quality, access,
member satisfaction, utilization and plan financial performance
Quality of Care Measures - include immunization rates; cervical cancer screening; asthma inpatient admission rate;
Only I AIDS measure in testing phase - PCP prophylaxis
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INFORMATION REQUIREMENTS
Three key areas of data: Enrollment, utilization, and cost
Accurate and timely information is crucial
Data helps staff to manage utilization and risk
Information provides the foundation for future planning
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TYPES OF REPORTS
MEMBERSHIP Accurate and timely membership report of enrolled and
disenrolled members CAPITATION
Compare capitation revenue to cost of providing service AGGREGATE UTILIZATION AND COST
Compare projected versus actual utilization and cost INDIVIDUAL PROVIDER UTILIZATION AND COST
Utilization and cost patterns for each primary care provider
HRSA HIV/AIDS Bureau 18
SELECTED DATA ELEMENTS
Data Element You Provide Managed Care Plan
Provides
Member Months X Capitation Revenue PMPM X
Primary Care Visits PMPM X
Cost of Primary Care PMPM X
Specialty Visits PMPM X
Ancillary Tests PMPM X
# of Primary Care Visits Per Provider X
# of Referrals per Provider X
# of Hosp/ital Admissions per Provider X
HRSA HIV/AIDS Bureau 19
RYAN WHITE PROGRAMS VERSUS MCOs
RYAN WHITE PROGRAMS public health mission
population driven
enabling services
medically and culturally appropriate providers
provide care to uninsured
accessible sites
experience with vulnerable populations
MCOs for profit mission
market driven
mandated benefits only
cost efficient contracted providers
care only to members
“commercial” sites
experience with middle class