MANAGED CARE

1. MANAGED CARE

2. MANAGED CARE PLANS COMBINE THE DELIVERY OF HEALTH CARE WITH THE FINANCING OF THAT CARE.

3. IN A MANAGED CARE PLAN, SUCH AS A HEALTH MAINTENANCE ORGANIZATION (HMO) OR A PREFERRED PROVIDER ORGANIZATION (PPO), YOU RECEIVE YOUR HEALTH CARE FROM A GROUP OF PHYSICIANS, HOSPITALS, AND OTHER SERVICE PROVIDERS SELECTED BY THE PLAN.

4. IN EXCHANGE, YOU PAY A SET MONTHLY FEE FOR THE SERVICES YOU RECEIVE.

5. TYPES OF MANAGED CARE PLANS

6. HEALTH MAINTENANCE ORGANIZATION

7. GROUP AND STAFF MODEL HMO’S ARE THE MOST RESTRICTIVE AND PROVIDE FEWER CHOICES OF PROVIDERS TO CONSUMERS.

8. ON THE OTHER HAND, THIS MODEL OFTEN OFFERS ONE-STOP CARE WHICH MEANS THAT ALL YOUR DOCTORS, AS WELL AS LABORATORY AND X-RAY SERVICES ARE X-RAY SERVICES ARE LOCATED IN ONE MEDICAL FACILITY.

9. IN A GROUP OR STAFF HMO, YOU MUST CHOOSE A PRIMARY PHYSICIAN. IF YOU DON’T, THEY WILL CHOOSE ONE FOR YOU.

10. INDIVIDUAL PRACTICE ASSOCIATONS (IPA’S) • INDIVIDUAL PRACTICE ASSOCIATIONS (IPA’S) ARE A LESS RESTRICTIVE FORM OF HMO THAN THE GROUP OR STAFF MODEL.

11. INDIVIDUAL PHYSICIANS PRACTICING IN THEIR OWN OFFICES ARE UNDER CONTRACT TO A SEPARATE GROUP, CALLED AN “IPA” THAT, IN TURN, CONTRACTS WITH AN HMO.

12. THE HMO PROVIDES YOU WITH A LIST OF PARTICIPATING PHYSICIANS FROM WHICH YOU MAY CHOOSE YOUR PRIMARY CARE DOCTOR.

13. VISITS TAKE PLACE IN THE DOCTOR’S OFFICE. IF YOU REQUIRE SPECIALITY CARE, YOUR PRIMARY CARE DOCTOR REFERS YOU TO A PARTICIPATING SPECIALIST.

14. BY FAR THE LARGEST NUMBER OF HMO MEMBERS ARE ENROLLED IN THE IPA MODEL.

15. PHYSICIANS MAY BELONG TO MORE THAN ONE HMO AND ALSO MAY CONTINUE TO SEE FEE-FOR-SERVICE PATIENTS IN THEIR OFFICE.

16. POINT OF SERVICE (POS) • POINT OF SERVICE (POS) PLANS PERMIT MEMBERS GREATER CHOICE AND FLEXIBILITY BY ALLOWING YOU THE OPTION OF GOING “OUT OF PLAN” TO USE NON-HMO PROVIDERS.

17. IF YOU GO “OUT OF PLAN,” YOU MUST PAY MORE, TYPICALLY IN THE FORM OF HIGH COINSURANCE AND DEDUCTIONS.

18. PREFERRED PROVIDER ORGANIZATION (PPO)

19. PREFERRED PROVIDER ORGANIZATION (PPO) ARE NETWORKS OF DOCTORS AND HOSPITALS THAT HAVE AGREED TO GIVE THE SPONSORING ORGANIZATION DISCOUNTS ON THEIR USUAL RATES. (USUALLY AN EMPLOYER OR INSURANCE COMPANY).

20. SOME PPO’S USE PRIMARY CARE PHYSICIANS AS GATEKEEPERS.

21. IN OTHERS, YOU MAY CHOOSE YOUR OWN DOCTORS AND VISIT SPECIALISTS WITHOUT PERMISSION FROM A GATEKEEPER.

22. PPO’S OFFER YOU THE GREATEST FREEDOM AMONG MANAGED CARE PLANS IN SELECTING HEALTH CARE PROVIDERS BUT PPO PREMIUMS ARE USUALLY SOMEWHAT HIGHER THAN HMO PREMIUMS AND THERE IS LESS COORDINATION OF CARE.

23. DEFINED CARE • Employer sponsored Defined Contribution Health plans. • Provides an allowance that empowers consumers to purchase and select from a wide menu of benefit options

24. MANAGED CARE VS. TRADITIONAL HEALTH INSURANCE

25. RECEIVING CARE • GATEKEEPERS

26. UNDER FEE-FOR-SERVICE INSURANCE OR TRADITIONAL HEALTH INSURANCE, YOU CAN CHOOSE ANY LICENSED PHYSICIAN TO BE YOUR PERSONAL DOCTOR AND YOU CAN THE SERVICES OF ANY HEALTH CARE FACILITY OR SERVICES.

27. UNDER MANAGED CARE, MEMBERS RECEIVE CARE THAT IS PROVIDED DIRECTLY OR AUTHORIZED BY THE MANAGED CARE PLAN.

28. THE PRIMARY CARE DOCTOR YOU CHOOSE BECOMES YOUR PERSONAL PHYSICIAN AND COORDINATES YOUR CARE.

29. THE DOCTOR ACTS A “GATEKEEPER,” TREATING YOU DIRECTLY OR AUTHORIZING YOU TO HAVE TESTS, SEE A SPECIALIST, OR ENTER A HOSPITAL.

30. THE “GATEKEEPER” ARRANGEMENT IS DESIGNED TO PROVIDE THE NECESSARY CARE AT THE LOWEST COST AND TO AVOID GIVING UNNECESSARY CARE.

31. QUALITY REVIEW • UNDER TRADITIONAL HEALTH INSURANCE PLANS, DOCTORS PRACTICE INDEPENDENTLY WITH LITTLE OR NO ASSESSMENT OF THEIR PERFORMANCE BY THEIR PEERS OR GOVERNMENT REGULATORS.

32. MANAGED CARE PLANS USUALLY HAVE QUALITY REVIEW PROCEDURES THAT MAY INCLUDE INTERNAL AND EXTERNAL QUALITY ASSURANCE PROGRAMS.

33. PLANS “FEDERALLY QUALIFIED” TO PROVIDE HEALTH CARE TO MEDICARE OR MEDICAID ENROLLEES, UNDER LAW MUST HAVE QUALITY ASSURANCE PROGRAMS.

34. THE OVERALL PERFORMANCE OF THE PLAN IS MONITORED THROUGH GOVERNMENT OVERSIGHT, PATIENT SATISFACTION SURVEYS, DATA FROM GRIEVANCE PROCEDURES, AND INDEPENDENT REVIEWS.

35. UTILIZATION REVIEW

36. MANAGED CARE PLANS REVIEW THE MEDICAL CARE PROVIDED BY YOUR DOCTORS TO DETERMINE WHETHER OR NOT IT IS APPROPRIATE AND NECESSARY.

37. WHEN HOSPITAL CARE IS INDICATED, OTHER FACTORS AND SAFEGUARDS IN THE UTILIZATION REVIEW INCLUDE:

38. CARE IN ADVANCE. WITHOUT IT, THE PLAN MAY PREADMISSION CERTIFICATION: APPROVAL FOR NOT PAY FOR NON-EMERGENCY SERVICES.

39. CONCURRENT REVIEW: MANAGED CARE PLANS MONITOR YOUR HOSPITAL STAYS TO BE SURE THEY ARE NO LONGER THAN ABSOLUTELY NEEDED AND THAT ALL TESTS AND PROCEDURES ORDERED ARE MEDICALLY NECESSARY.

40. DISCHARGE PLANNING: PLANS WANT TO KEEP HOSPITAL STAYS TO THEIR SHORTEST APPROPRIATE LENGTH. IF NECESSARY, THE PLAN WILL ARRANGE POST-HOSPITAL CARE, INCLUDING NURSING HOME OR HOME HEALTH CARE.

41. CASE MANAGEMENT: CASE PLANS ARE DEVELOPED FOR COMPLICATED CASES TO BE SURE CARE IS COORDINATED AND PROVIDED IN THE MOST COST-EFFECTIVE MANNER.

42. SECOND SURGICAL OPINIONS: • PLANS MAY REQUIRE A SECOND OPINION BEFORE SCHEDULING ELECTIVE SURGERY. THE SECOND PHYSICIAN MAY BE ASKED TO JUDGE THE NECESSITY OF THE SURGERY AND ALSO TO EXPRESS AN OPINION ON THE MOST ECONOMICAL, APPROPRIATE PLACE TO PERFORM THE SURGERY.

43. PAYING FOR CARE

44. FOR MOST PEOPLE WITH TRADITIONAL HEALTH INSURANCE, PREMIUMS ARE ONLY ONE PART OF THE COST. CONSUMERS ALSO PAY DEDUCTIBLES, COINSURANCE, AND THE COST OF SERVICES THAT ARE NOT COVERED.

45. WITH MANAGED CARE, OUT-OF-POCKET COSTS ARE GENERALLY LOWER, AND THERE IS FAR LESS PAPERWORK FOR PLAN MEMBERS TO CONTEND WITH.

46. THE PROS AND CONS

47. HMO STAFF MODEL: • PROS: CENTRALIZED FACILITY WHERE CARE IS PROVIDED AND COORDINATED; LOW COPAYMENTS; PREVENTATIVE CARE; NO CLAIM FORMS. • CONS: MUST USE DOCTOR IN THE HMO; PLAN MUST APPROVE TREATMENT AND MAKE REFERRALS.

48. HMO INDIVIDUAL PRACTICE ASSOCIATION: • PROS: PROVIDERS USE THEIR OWN OFFICES; LOW COPAYMENTS; PREVENTATIVE CARE; NO CLAIM FORMS. • CONS: MUST USE DOCTORS IN THE HMO; PLAN MUST APPROVE TREATMENT AND MAKE REFERRALS.

49. HMO POINT OF SERVICE: • PROS: MORE CHOICE OF PROVIDERS OUTSIDE THE NETWORK; LOWER COST WITHIN THE NETWORK; PREVENTIVE CARE COVERED. • CONS: HIGHER COST OUTSIDE THE NETWORK; OUT-OF-NETWORK COVERAGE MAY BE LIMITED; PLAN MUST SOMETIMES APPROVE TREATMENT AND MAKE REFERRALS.

50. PREFERRED PROVIDER ORGANIZATION (PPO): • PROS: CHOICE OF STAYING IN OR GOING OUT OF THE NETWORK FOR CARE. LOWER COST IF PROVIDERS WITHIN NETWORK ARE USED. • CONS: HIGH COST OUTSIDE THE NETWORK; ADDITIONAL PAPERWORK TO SECURE APPROVAL FOR SOME SERVICES; LIMITED COORDINATION OF CARE.