Managed Care Key Terms 

Define and explain the following:

• Capitation: a payment arrangement in healthcare where a provider is paid a fixed amount per patient for a specific period, regardless of the number or type of services provided. This amount is usually set per member per month (PMPM) and is intended to cover all of a patient's healthcare needs during that time frame. 

• Discounted feeds: refer to reduced prices or charges offered by a service provider, often as part of a promotion or special agreement. In the context of healthcare, discounted fees typically involve providers offering lower rates for services to certain patients, insurance plans, or groups. This can be part of an arrangement where a healthcare provider or insurer negotiates lower prices for services to attract more clients, manage costs, or promote affordability. 

• Fee Schedule: a list of pre-established prices or rates for specific services, procedures, or treatments provided by a healthcare provider, insurance company, or other service entity. It outlines how much a provider will charge for each service, often based on agreements with insurance companies, government programs like Medicare or Medicaid, or other entities. 

Cost Control Methods

• Choice Restriction: Limiting the choices that are available to help people towards a specific choice. 

• Care Coordination: Organizing a patient's care across many healthcare providers. They make sure they are safe, effective, and high-quality care.  

• Disease Management: Aim to improve the quality of life for people who suffer from chronic conditions while reducing healthcare costs.  

• Pharmaceutical Management: Manage the patient using the appropriate use of pharmaceuticals within a health system. 

• Utilization Review: ensures patients receive the correct care in the right setting. They evaluate a patient's care plan and determine what is necessary for a patient. 

• Practice Profiling: Breaking down the elements to evaluate and define various aspects of healthcare delivery.