Yoder-Wise’s Leading and Managing in Canadian Nursing, 3rd Edition Yoder-
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Chapter 09:The Canadian Health Care System
Waddell/Walton: Yoder-
Wise’s Leading and Managing in Canadian Nursing, Third Edition
Composed of similar types of organizations offering similar product s
Market Sector
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Refers to a group of consumers with common characteristics, such as age, gender, or
level of income
Market Segment
vb
Health services include those that anyone throughout society may find usef ul
Mass Market
vb
Constitutes only those services used by restricted segments of the populatio n
Niche Services
vb
Required for management
Setting strategy, financing operations and expansion, ensuring favorable relations with the public
and other organizations, resolving internal conflict, and promoting productivity and morale
Levels of Mass Market Pr
imary
Secondary T
ertiary (Quat
ernary)
7. PCP
Primary Care Provider
,Yoder-Wise’s Leading and Managing in Canadian Nursing, 3rd Edition Yoder-
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Includes interventions that are at once highly specialized and rarely used. It is deliver ed
at only the most specialized facilities.
Quaternary Care
Function as the basic units of the health care syste m
Ambulatory care facilities or out-patient
EMTALA
Emergency Medical Treatment and Active Labor Act
Mandates that all facilities receiving Medicare funds must treat anyone with a n
emergency and may not transfer them until they are stabilized
EMTALA
Refers to an arrangement under which an administrative entity may take the form of a s
cheduling bureaucracy, case manager, or utilization review agency
Managed Care
Health Maintenance Organizations
HMOs
Types of Managed Care
Health Maintenance Organization
Independent Practice Associatio
n Preferred Provider Organizatio
n
Prospective agreements to care for a specified population for a fixed period of ti m
e Capitated Contracts
, Yoder-Wise’s Leading and Managing in Canadian Nursing, 3rd Edition Yoder-
vb vb vb vb vb vb vb vb vb
Nonprofit organization which retains physicians under exclusive contract. Owns and/ or
contracts with hospitals and have tight utilization review and practice conservative st
yle of medicine.
HMO
Physicians are paid by salary with risk sharing bonus and or withholdi ng
HMO
Patient access is limited to plan physicians and hospital
HMO
No charge beyond small copayment for in-network care; no coverage of out-of-
network HMO
For-
profit organization that combines individual physician practices into entities that contr
act independently with health plans. Physician keeps their practice and sees patients in
their office. Physician contract is not exclusive.
IPA
Serves as an entity to negotiate contracts on behalf of individual physicians. Physicia ns
are primarily paid on a capitation basis with possible risk sharing.
IPA
Have strong utilization review mechanisms, but allowing physicians to join multipl e
organizations may weaken their impact
IPA
Care normally limited to plan physicians and hospital
s IPA
vb vb vb vb vb vb vb vb vb
Chapter 09:The Canadian Health Care System
Waddell/Walton: Yoder-
Wise’s Leading and Managing in Canadian Nursing, Third Edition
Composed of similar types of organizations offering similar product s
Market Sector
vb
Refers to a group of consumers with common characteristics, such as age, gender, or
level of income
Market Segment
vb
Health services include those that anyone throughout society may find usef ul
Mass Market
vb
Constitutes only those services used by restricted segments of the populatio n
Niche Services
vb
Required for management
Setting strategy, financing operations and expansion, ensuring favorable relations with the public
and other organizations, resolving internal conflict, and promoting productivity and morale
Levels of Mass Market Pr
imary
Secondary T
ertiary (Quat
ernary)
7. PCP
Primary Care Provider
,Yoder-Wise’s Leading and Managing in Canadian Nursing, 3rd Edition Yoder-
vb vb vb vb vb vb vb vb vb
Includes interventions that are at once highly specialized and rarely used. It is deliver ed
at only the most specialized facilities.
Quaternary Care
Function as the basic units of the health care syste m
Ambulatory care facilities or out-patient
EMTALA
Emergency Medical Treatment and Active Labor Act
Mandates that all facilities receiving Medicare funds must treat anyone with a n
emergency and may not transfer them until they are stabilized
EMTALA
Refers to an arrangement under which an administrative entity may take the form of a s
cheduling bureaucracy, case manager, or utilization review agency
Managed Care
Health Maintenance Organizations
HMOs
Types of Managed Care
Health Maintenance Organization
Independent Practice Associatio
n Preferred Provider Organizatio
n
Prospective agreements to care for a specified population for a fixed period of ti m
e Capitated Contracts
, Yoder-Wise’s Leading and Managing in Canadian Nursing, 3rd Edition Yoder-
vb vb vb vb vb vb vb vb vb
Nonprofit organization which retains physicians under exclusive contract. Owns and/ or
contracts with hospitals and have tight utilization review and practice conservative st
yle of medicine.
HMO
Physicians are paid by salary with risk sharing bonus and or withholdi ng
HMO
Patient access is limited to plan physicians and hospital
HMO
No charge beyond small copayment for in-network care; no coverage of out-of-
network HMO
For-
profit organization that combines individual physician practices into entities that contr
act independently with health plans. Physician keeps their practice and sees patients in
their office. Physician contract is not exclusive.
IPA
Serves as an entity to negotiate contracts on behalf of individual physicians. Physicia ns
are primarily paid on a capitation basis with possible risk sharing.
IPA
Have strong utilization review mechanisms, but allowing physicians to join multipl e
organizations may weaken their impact
IPA
Care normally limited to plan physicians and hospital
s IPA
