MCOs (privatization & corporatization) - Answers These are companies that manage health
insurance plans by working with health providers and facilities to offer cost-effective and quality
care to members.
Privatization: The process by which healthcare services, previously run by the government, are
transferred to private companies.
Corporatization: The transformation of healthcare facilities and services into business-like
entities, focusing on efficiency and profitability, even if they are still owned by the public sector.
Goals of Managed Care - Answers Reduce healthcare costs.
Improve the quality of care.
Make sure patients have access to necessary healthcare services.
Local Public Health Departments - Answers provide services to local communities—focusing on
the reporting of communicable diseases, public health nursing, health education, environmental
sanitation, maternal and child health services, and public health clinics.
HMO (Health Maintenance Organization) - Answers A type of health insurance plan that
provides healthcare services to members through a network of doctors, hospitals, and other
providers for a fixed, prepaid fee.
Medicare (all parts) - Answers Part A: Covers inpatient hospital stays, care in a skilled nursing
facility, hospice care, and some home health care.
Part B: Covers certain doctors' services, outpatient care, medical supplies, and preventive
services.
Part C (Medicare Advantage): Offers an alternative way to receive Medicare benefits through
private insurance plans that cover all Part A and Part B services and sometimes additional
services.
Part D: Provides prescription drug coverage.
, Medicare - Answers A federal health insurance program in the United States primarily for people
aged 65 and older, as well as for some younger people with disabilities and those with End-
Stage Renal Disease.
Payment Methods - Answers Fee-for-Service: Providers are paid for each individual treatment or
service they render.
Capitation: Providers receive a set payment for each enrolled patient regardless of the number
of services provided.
Salary: Providers are paid a fixed salary by the employer, such as a hospital or clinic.
Bundled Payment: Providers receive a single bundled payment for all services related to a
specific treatment or condition over a defined period.
Pay-for-Performance: Providers are incentivized with bonuses for meeting specific quality
benchmarks or improving patient outcomes.
ACA (Affordable Care Act) - Answers A comprehensive healthcare reform law enacted in March
2010, often known as Obamacare, aimed at expanding health insurance coverage, controlling
healthcare costs, and improving the healthcare system.
Group Health Plans - Answers Health insurance plans that provide coverage to members of a
group, such as employees of a company or members of an organization, typically with shared
costs between the employer and the employees.
Integrated Systems (IDS) - Answers Networks of healthcare providers and facilities that work
together to offer a coordinated range of services to a specific population, with the goal of
providing comprehensive care and improving health outcomes.
IDS Models - Answers Different organizational structures in healthcare that integrate primary
care, specialty care, hospital services, and sometimes health insurance under one entity to
provide comprehensive care. Examples include:
Horizontal Integration: Multiple hospitals or clinics coming together to offer a broad network of
the same level of care.