Question

1. What is a withhold feature for payment to health care providers?
2. What promotes the growth of Integrated Delivery Systems?
3. Why are capitation plans more common for physician payments?
4. The James Clinic is an organization of 100 physicians in a variety of specialties. They recently contracted with Prudential Health Plan on a capitated basis to provide all medical services to Prudential's members for the next three years. What would this HMO model be defined as?
5. What provision would a medical group include in its contract with an HMO to receive larger PMPM payments if the HMO members are chronically ill?
6. You are trying to establish a PMPM rate for Primary Care Physicians. Actuarial estimates project 2,500 visits per 1,000 members per year. You have contracted with a Primary Care Medical group at $45.00 per visit with a $5.00 copayment that you will receive. What PMPM rate should you set?

Answer 1

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What is a withhold feature for payment to health care providers?

Provides a mechanism for reducing risk to the payer.

What promotes the growth of Integrated Delivery Systems?

Cutting out the middleman (many hospitals now have formed insurance companies that sell plans to their employees).

Why are capitation plans more common for physician payments?

Becase it holds the physician at financial risk for services provided to the patient. The amount of capitation is determined by the number of services provided and vary from health plan to health plan.

The James Clinic is an organization of 100 physicians in a variety of specialties. They recently contracted with Prudential Health Plan on a capitated basis to provide all medical services to Prudential's members for the next three years. What would this HMO model be defined as?

                Group Model

What provision would a medical group include in its contract with an HMO to receive larger PMPM payments if the HMO members are chronically ill?

Adverse Selection

You are trying to establish a PMPM rate for Primary Care Physicians. Actuarial estimates project 2,500 visits per 1,000 members per year. You have contracted with a Primary Care Medical group at $45.00 per visit with a $5.00 copayment that you will receive. What PMPM rate should you set?

$17