hrsa hiv/aids bureau1 hiv/aids bureau health resources and services administration fundamentals of...

HRSA HIV/AIDS Bureau 1

HIV/AIDS BUREAU

HEALTH RESOURCES AND

SERVICES ADMINISTRATION

FUNDAMENTALS OF MANAGED CARE


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


HMOS

PPO PHO

ISN

IPA

TPA

POS

PCCM

IDS

IPO

THE ALPHABET SOUP OF MANAGED

CARE

SSO

MCO

MCP

MCE


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)


ORGANIZATIONAL PERSPECTIVE

State (or employer)State (or employer)

Managed Care Organization (MCO)


InpatientProviders

InpatientProviders

Primary CareProviders


Specialty/OtherProviders


Premium $$$$

$$$

$$$$ $$$$

State (or employer)State (or employer)



InpatientProviders

InpatientProviders






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


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


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


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


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


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)


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


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


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


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


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


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


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


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

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