Managed care is an all
inclusive system that brings together both delivery and payment. This system
utilizes management techniques that gear towards promoting the delivery of
healthcare in a way that is most cost effective. The contract between two
entities such as a doctor or other health care related businesses is an
important resource that defines the relationship. Any type of provision within
the contract may directly affect organizations outcomes through payment,
procedures, and even clinical decision making. Below are eight different
managed care contracting terms and their definition.
Medical Plan, also known as CMP, is given to certain organizations that meet
certain requirements. This status grants the organizations that meet those
specific requirements the ability to obtain a Medicare risk or cost based
in is a contractual provision in which members may receive their care only from
health providers in network. The only exception is in cases where emergency or
urgent care is needed.
or Tax Equity and Fiscal Responsibility Act of 1982 is a managed care contract
term. TEFRA is the Federal law that is
responsible for the creation of the current risk and cost contract provision.
- Preferred Providers is a term used to identify
physicians, clinics, or other health care providers that are associated with a
particular health plan.
Health Plan, also known as PHP operates on a prepaid basis. The services this
plan provides are those that are not risk comprehensive. They contract on a non
risk basis. There are some entities that are treated as PHP’s only if they meet
the criteria above.
or Preferred Provider Organization, is a type of system that negotiates with
medical care providers. PPO systems negotiate rates with medical care providers
for services given to members of this particular plan. Members are allowed to
seek medical care with providers that are not on the PPO plan, however, the
member will ultimately be financially responsible for the bill.
Model HMO is a model which forms relationships with more than one group of
physicians. This system may contract with either single or multi specialty
groups. These groups normally work out of their own office.
Health Care plan incorporates financing and management with the delivery of
health care services to a certain group of people. It contacts with an organized system of
providers that deliver services and often times shares financial risk.
Managed care has changed over the past ten years. In
2000 the national total HMO enrollment was 80.9 million. For the first time,
the national enrollment dropped by almost 1 million. Part D was established in
2003. Part D is a drug benefit program. Unlike today, people in the 1990’s were
free to choose a provider of their choice. Often times, physicians were not
questioned about their choices. Unfortunately, that is not the case Today,
companies are still trying to control the cost of health care for their
employees. They try to introduce specific guidelines to professionals in order
to improve medical provider choices. Although the future of health care
management is uncertain, our government works vigorously to ensure we receive
proper health care.