Health Care Models - Ccma
- What is primary care in the health care delivery system?
- First-contact, comprehensive care for common health needs. Serves as the entry point, addressing most needs to prevent escalation to higher levels.
- What is capitation in a managed care payment model?
- Fixed per-member, per-month payment regardless of services used. Providers receive a set fee per enrolled patient periodically, shifting risk to manage costs within that amount.
- What is hospice care as a delivery model for serious illness?
- Comfort-focused end-of-life care emphasizing symptom management. Prioritizes quality of life and palliation for terminally ill patients and families.
- What is tertiary care in the health care delivery system?
- Highly specialized care for complex conditions and procedures. Involves advanced interventions in facilities equipped for intensive care.
- What is a patient-centered medical home (PCMH) model?
- Primary care model emphasizing coordinated, team-based care. Enhances access and continuity through a central hub for preventive and chronic care management.
- What is an HMO (Health Maintenance Organization)?
- Managed care plan with network limits and PCP-coordinated care. Emphasizes preventive care and cost control through gatekeeping and restricted networks.
- What is an accountable care organization (ACO)?
- A provider group jointly accountable for quality and total cost. Collaborative structure shares financial risks and rewards for Medicare populations.
- What is a formulary in an organizational structure for medication coverage?
- A covered-drug list used by a health plan or pharmacy benefit. Guides prescribing to cost-effective, evidence-based medications within plans.
- What is quaternary care in the health care delivery system?
- Ultra-specialized, experimental, or rare-condition care services. Represents the pinnacle of specialization, often in academic or research settings.
- What is home health care as a health care delivery model?
- Skilled services provided in the patient home under a care plan. Supports recovery and independence for patients unable to travel to facilities.
- What is a solo practice organizational structure in outpatient care?
- A single physician (or provider) operates an independent practice. Provides autonomy and personalized care but limits scalability and support.
- What is a POS (Point-of-Service) plan in managed care?
- Hybrid plan allowing out-of-network care with higher patient cost. Combines HMO structure with PPO-like options for greater patient autonomy.
- What is a hospitalist model of inpatient care delivery?
- Inpatient care is managed primarily by hospital-based physicians. Specializes in hospital settings to improve continuity and reduce errors.
- What is an emergency department (ED) as a delivery setting?
- 24-hour care for acute illness or injury requiring immediate attention. Handles life-threatening conditions with rapid, specialized resources around the clock.
- What is a referral in a managed care organizational structure?
- Authorization for a patient to receive specialty care from a PCP. Ensures appropriate utilization by directing patients to specialists via primary oversight.
- What is a bundled payment model for an episode of care?
- One combined payment for all services in a defined episode. It consolidates costs for a treatment period, promoting efficiency and coordination among providers.
- What is secondary care in the health care delivery system?
- Specialty care typically provided after referral from primary care. Focuses on specialized diagnostics and treatments, building on initial assessments.
- What is the fee-for-service (FFS) payment model in health care delivery?
- Payment is made for each individual service provided. This model reimburses providers per procedure or visit, encouraging volume-based care rather than outcomes.
- What is an EPO (Exclusive Provider Organization)?
- Plan that generally covers only in-network care (except emergencies). Restricts coverage to designated providers to streamline costs and care quality.
- What is a multispecialty group practice organizational structure?
- One organization employing multiple specialties under one group. Enables comprehensive services through shared resources and collaboration.
- What is a PPO (Preferred Provider Organization)?
- Plan with broader choice; lower costs for in-network providers. Offers flexibility in provider selection while incentivizing network use for lower out-of-pocket costs.
- What is prior authorization (preauthorization) in insurance models?
- Payer approval required before a specific service is provided. Controls expenses and ensures medical necessity before high-cost interventions.
- What is value-based care as a health care delivery approach?
- Care is reimbursed based on outcomes, quality, and cost control. Shifts focus from volume to measurable improvements in patient health and resource use.
- What is an urgent care center as a delivery setting?
- Walk-in care for non-life-threatening needs outside routine hours. Bridges gaps in access for timely, non-emergent treatment without appointments.
- What is an integrated delivery system (IDS)?
- Network coordinating hospitals, providers, and services across care. Facilitates seamless transitions and efficiency across continuum of care settings.