2. Chapter 23
Managed Care
2

3. Models of Managed Care
Organizations - I
• Health Maintenance Organizations
• Preferred Provider Organizations
• Exclusive Provider Organizations
• Point of Service Plans
• Experience-Rated HMOs
3

4. Models of Managed Care
Organizations - II
• Specialty HMOs
• Independent Practice Associations
• Group Practice
• Group Practice without Walls
4

5. Models of Managed Care
Organizations - III
• Physician Hospital Organizations
• Medical Foundations
• Management Services Organizations
• Vertically Integrated Delivery System
• Horizontal Consolidations
5

6. Managed Care – I
• Federally Qualified HMOs
• State Laws
• Case Management Firms
• Third-Party Administrators
6

7. Managed Care – II
• Utilization Review
Prospective review
Concurrent review
Retrospective review
• Utilization Management Firms
Negligent UR Decisions
7

8. Managed Care – III
• Liability for Nonparticipating Physicians
• Employee Retirement Insurance Security Act
• Reducing Exposure to Liability
• Health Care Quality Improv. Act – 1986
• Open Enrollment
• Emergency Care
• Ethics in Patient Referral Act (1989)
8

9. Managed Care & Legal Actions
• Financial incentives disclosed
• Insurer and tort-feasor
• Benefit denials
• False and misleading statements
9

10. Market Power
• Product Market
• Geographic Market
• Provider exclusion
• Antitrust & Market Share
10

11. REVIEW QUESTIONS
1. Describe the more common models of MCOs.
2. What are the advantages & disadvantages of
HMOs?
3. What is the purpose of utilization review?
4. Why did Congress pass the health care quality
improvement act of 1986?
5. What is price-fixing?
11