For this week’s project, I have interviewed an expert to better understand the complexities of physician reimbursement (South University, n.d.). I have interviewed Gwen Robinson RN, MBA. Mrs. Robinson is an experienced long-term healthcare administrator at Jolley Aces Healthcare, located in Orangeburg S.C. Mrs. Robinson has been an administrator for 15 years. What kind of risk do the MCOs assess?
Managed Care Organizations (MCOs) use fully capitated plans that offer a core benefit package. Using a capitation plan a fixed payment to providers is provided for each covered life, or enrollee, regardless of the number of services received. MCO plans are required to provide "medically necessary" care to members for all contracted services. The risk these MCOs face is financial jeopardy if their spending on healthcare services and administration exceeds their payments.
Does risk-based compensation limit the freedom of primary care physicians in any way in terms of patient care? Why or why not?
Yes, Different risk-based models’ subject participants to varying degrees of risk. The goal of risk-based payment systems is to make providers responsible for providing better, more effective
treatment. Full-risk practices give doctors the financial freedom to treat patients when they need it without worrying about whether it will be billed (SCDHHS, 2021).
How does the capitation model of reimbursement work? Do physicians prefer one model over the other? Why or why not?
Capitation model of reimbursement is a monthly cash amount per member enrolled in a managed
care plan. Physicians or other healthcare professionals receive a set payment regularly known as capitation as the only compensation for services rendered (SCDHHS, 2021). “For example, a
