ONCOLOGY.
No. 1
What Is Proper Cancer Care in the Era of Managed Care?
By
Grace Powers Monaco, JD, Medical Care Ombudsman Program, King
George, Va.
Peter Goldschmidt, MD, DRPh, DMS, Medical Care Management
Corporation,Bethesda, Maryland
|
January 1, 1997
Glossary of Key Terms
Exclusive provider organization (EPO)
A managed-care plan that covers only those services delivered by a
specified provider network (except for emergency care, for example). Technically,
an HMO is usually an EPO, except that the term "EPO" connotes
a network akin to a PPO.
Group model health maintenance organization (HMO)
An HMO that contracts for services predominantly with a single, independent
group practice, usually in HMO-owned or -managed facilities.
Health maintenance organization (HMO)
An organization that agrees to provide a defined (often comprehensive)
range of health services to an individual (or group) for a specified period
(usually a year) in exchange for a prospective (usually monthly) per capita
(or sometimes per family) subscription (payment).
Individual (independent) practice (physician) association (IPA)
An entity that enters into an arrangement for the provision of health-care
services with licensed medical practitioners and other health-care providers,
often for the purpose of contracting with managed-care organizations to
deliver services to their enrollees.
Integrated delivery system (IDS)
A health-care system under single management that provides primary
care, secondary (specialist and hospital) care, and often tertiary (highly
specialized) care, nursing home care, home care, and other services, usually
to effect coordination of services and to achieve economies of scale. Sometimes
called a vertically integrated delivery system.
Managed-care organization (MCO)
A broad term that refers to a managed-care plan or a managed-care company.
It encompasses such entities as health maintenance organizations and preferred
provider organizations, for example. Managed-care organizations combine
both health insurance and health-care delivery functions. They usually
deliver care to their enrollees (also referred to as members or subscribers)
through staff, an allied group, or a network of contracted providers.
Managed indemnity
A traditional indemnity health insurance plan that includes such elements
of utilization management as preprocedure review, for example. Sometimes
called managed fee-for-service insurance.
Network (managed care network)
An organization that provides health-care services to one or more defined
populations (for example, individuals who enroll in the MCO or employees
of companies that contract with the MCO for services). An HMO, PPO, insurer,
or any other entity consisting of provider organizations and insurers may
form a network to contract with purchasers to provide health care. An employer
may create a network to provide care for its employees. The network's organizer
coordinates and integrates services provided by the network's components,
for example, multispecialty group practices.
Physician-hospital organization (PHO)
An entity created by a hospital and a physician group, usually to obtain
managed-care contracts that the entity negotiates directly with employers.
Point of service (POS) plan
A managed-care plan whose members may choose their provider (and hence
plan) at the time of service. Usually, the plan covers more of the cost
of care if the patient chooses a participating provider (for example, care
delivered by an HMO or within a PPO) and less of the cost of care if the
patient decides to use a provider outside of the plan, with the patient
making up the difference. Sometimes called managed choice.
Preferred provider organization (PPO)
An MCO that contracts with providers to deliver specified health-care
services to a defined population (enrollees) at a discount. A PPO usually
has the following three characteristics: discounted provider fees in exchange
for a guaranteed volume of patients; monetary incentives for enrollees
to use network (preferred) providers; and broad-based utilization management
programs.
Primary-care physician (provider, practitioner) (PCP)
A individual who is a person's primary contact within the health-care
system and who delivers or manages the person's routine health-care needs.
In managed-care organizations, patients usually must first see a primary-care
physician to obtain any needed specialty care (hence the term "gatekeeper").
Staff-model health maintenance organization (HMO)
An HMO that delivers services though a physician group that it controls;
physicians are usually salaried employees of the group.
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