US Health Care System

Topics: Health insurance, Preferred provider organization, Managed care Pages: 12 (683 words) Published: March 19, 2015
US Health Care System
An

explanation of what a managed
care organization (MCO) is and how
MCOs
evolved
The identification of the accrediting
bodies for MCOs and an explanation of
the types of care they oversee.
A description of managed care plans,
such as HMOs and PPOs
explanation of the impact of MCOs on
cost, access, and quality.
An explanation of what accountable
s

3/19/15

What is managed care
organization (MCO)?
Managed Care is a system that s structured
to regulate cost, operation, and value of
care, which provides the distribution of
health benefits and addition to the services
that are negotiated from state to state
Medicaid groups. This would also include
Medicaid organizations and managed care
associations (MCO) that collects from every
member on every month.

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MCOs Evolves.
HMO- Require a lower copayment for an doctors visit,
hospital stays, and for pharmaceuticals. A monthly flat fee
is collected from everyone that is under their plan
FFS- fee-for-service covers all medical expenses , with no
provider networks or tiers to follow.
IPA - Independent Physician Association, physicians that join together as a network, but independently negotiate with
other organizations who are contracted with one or more
MCO organization .
PPO- Preferred Provider Organization allow visits to innetwork doctors or healthcare provider with out a referral from the primary doctor.
POS- Point of Service Plans is a plan that mimic HMO’s and 3/19/15
PPO’s, the levels of benefit depending
on care received in –

The identification of the
accrediting bodies for MCOs
• What is Accreditation?
Accreditation is a health plan
arbiter to measure effective
service.

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Identification of the accrediting

•Access and Services•Qualified Providers
•Mantling good health
•Health continues
plans to getting health
•Living with Illnesses
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Why is Accreditation
Important?
Accreditation is important to inspire
health plans developers to effectively
improve quality, and to stay
consistent with other health plan
providers.

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How Does Accreditation
Work?
The NCQA’s has requirement 
that are held to a high standard 
to support the health plans and  
consumers.
3/19/15

A description of managed care plans,
HMOs and PPOs.

HMO’s require the
consumer to have a primary
health care physician.
PPO’s the network of
physicians has contracts, no
need for an referral from a
primary physician.
3/19/15

An explanation of the impact of
MCOs on cost, access, and
quality
The implication on managed care has a
tremendous effect on the cost, access and
quality. Manage care focuses on medical
practices that allows physicians to make
the decisions without interruption. Having
MCO’s allows for a lower cost. Managed
care also provides treatments and cost of
care for are aiming for quality. Studies
have shown technology that cost has
s
descended with managed care
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What is accountable care organization?

Accountable Care Organization (ACO)
A collective amount of doctors, hospital
and providers voluntarily gives high
quality care to their Medicare patients.

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Accountable care organization
and its relationship to MCOs
Managed Care Organization

Global Budget that is negotiated –risk sharing .

Insurance risks

PCP is contracted with HMO’s and referral
programs

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Reference
Baker, L. (2015, January 25). The Effect of HMO's on Fee-For-Service Health Care Expenditures. Retrieved from Evidence from Medicare. Journal of Health Economics: www.ncb.nih.gov/pmc/articals/PMC1360998/#!po=82.8125

CMS.gov. (2015, January 25). Center for Mecicare and Medicaid Services . Retrieved from Accountable Care Organizations: http://www.cms.gov/Medicare/Medicare-Fee-for-ServicePayment/ACO/index.html?redirect=/aco ehealthinsurance.com. (2015, January 25). Point of Service Insurance Plans. Retrieved from What is...
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