Medical Practice Strategies:  Systems Based Practice - Business Laws Ethics

Janet Lerman, J.D.

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New News - Class 1

The term "Consumer" is a broad term and includes "Patient".  The "Patient" is a "Consumer" of health services. 



The term "Caregivers" is a broad term and includes "Providers".


The term "Coverage" refers to the type of health insurance Consumers have.   Different types of entities provide health insurance coverage such as Managed Care Organizations ("MCOs") including Health Maintenance Organizations ("HMOs") and Preferred Provider Organizations ("PPOs").


The Patient Protection and Affordable Care Act (commonly referred to as "Affordable Care Act") has triggered the growth of various types of entities including:  Accountable Care Organizations ("ACOs), Accountable Care Entities ("ACEs"), Care Coordination Entities ("CCEs"), and Coordinated Care Organizations ("COO").

Per Centers for Medicare & Medicaid Services at  Accountable Care Organizations (ACOs) are groups of doctors, hospitals, and other health care providers, who come together voluntarily to give coordinated high quality care to their Medicare patients.  The goal of coordinated care is to ensure that patients, especially the chronically ill, get the right care at the right time, while avoiding unnecessary duplication of services and preventing medical errors.  When an ACO succeeds both in delivering high-quality care and spending health care dollars more wisely, it will share in the savings it achieves for the Medicare program.

The "Marketplace health plans" at indicates that all health plans on the website must offer the same essential health benefits.  The benefits include coverage for:   doctor visits, prescription drugs, hospitalization, maternity and newborn care, preventive care.  Plans can offer other benefits like vision, dental, or medical management programs for a specific disease or condition.  Plans are put into 4 metal type of categories with varying percentages of coverage.  The coverage categories are: Bronze (covers 60% of the total average costs of care); Silver (covers 70% of the total average costs of care); Gold (covers 80% of the total average costs of care); and Platinum (covers 90% of the total coverage costs of care). In general, the lower the premium, the higher the out-of-pocket costs for care.  The website for "Marketplace health plans" allows one to specify looking at plans with features based on dollar amount for the premium; coverage categories for the plans (such as bronze, silver, gold, and platinum); plan types (such as HMOs or PPOs); insurance companies providing the plans; and medical management programs (such as for asthma, heart disease, depression, diabetes, high blood pressure & cholesterol, low back pain, pain management, and pregnancy).



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