Company Case Study : Pt Company

First implemented in 1985 by Aetna (previously U.S. Healthcare), P4P programs were used to reward top performers and improve outcomes (Bruno, 2012). The incentives were meant to improve the quality of patient care by basing incentives on patient outcomes. Conversely, fee-for-service reimbursements are based on the treatments and set limits on the amount reimbursed for services. Because of these limits, incentives for use of pharmaceuticals and non-invasive procedures can impact how physicians practice.

This organization receives medical Claims from Private Physician Practices that need to be processed, coded, and filed accurately which then will get sent to the third-party payment system which is health insurance companies that each individual patient has. .

While Roger was at the VA hospital in Phoenix, an RN case manager came to talk with him. She did an assessment on him that included his medical and social background, so she could make sure that Roger has a safe discharge. Her job is to make sure that when Roger discharges from the hospital, he will have resources in place to help him get better, and to avoid getting so ill that he has to go back into the hospital.

Kaiser Permanente is a managed care facility that provides services across the health care continuum. Over the years the organization has continually made efforts toward improvements since it was first founded in 1945. These improvements generate a series of successes that set Kaiser apart from similar organizations. But, just as any health care delivery system, Kaiser has faced challenges in the past, present and may continue to do so in the future. In this paper I will explain what attributes to the success of Kaiser Permanente and some of the challenges they face.

According to the CMSA (Case Management Society of America) and several others organizations that case management alone means that it is a collective system that helps the patient and their family needs through the communication, available resources of promoted quality, and cost-effective outcomes.

80% of respondents reported that the lack of knowledge about the insurances accepted by the PCP is a major deterrent to why they have never referred to the PCP. 75 % reported the limited rapport with the PCP influences their limited or lack of referral to the PCP program. 85% of employees reported the limited understanding of the services offered by the PCP and their understanding of integration of care influences their decision not to refer to the PCP. 85% of the

Pharmacy benefits are managed for enrollee through cost savings and drug utilization management. PRT is a for-profit company, but its parent company TCTS is a non-profit organization. PRT offers generous benefits to its employees and constantly modifies its information technology IT infrastructure to be in sync and competitive with other competition. The cost savings are also passed onto to enrolled members through clinical review and mail order pharmacy savings. PRT signs contracts with different plans all within the TCTS coverage, and these plans are regulated and rated by CMS and TCTS. These ratings are dependent on feedback and results from reviews of request completed for enrolled members within a specific period of time. A standard request has a maximum or turn-around-time (TAT) of 72 hours, while an urgent

Professional organizations like medical practices, law offices, and accounting firms are required by law to obtain insurance to cover against wrongdoings committed by a principal or an agent of the business. However, increasing liabilities associated with possible wrongdoings and regular business operations require additional forms of protection. By changing to a limited liability partnership, professional organizations are better able to protect each partner in the case that something happens professionally. Unfortunately, wrongdoings committed by an individual partner negates the protection offered to him or her by the chosen business

Services are prepaid and providers are encouraged to utilize pre-approved treatment plans to manage disease (Nowicki, 2015). Providers are part of the managed care organization and their treatments are influenced by the organization’s choices on services that are provided to the patient (Nowicki, 2015). The patient’s care is managed by the primary care physician and case management professionals with the purpose of minimizing unnecessary treatments and is the most restrictive in delivering services.

The company’s Health Plan and Medical Services division provides health plan commercial risk, commercial management services, Medicare advantage coordinated care plans, and Medicaid products. It also offers commercial risk products, including health maintenance organization, preferred provider organization, and point of service products to individuals and employer groups. In addition, this segment provides health insurance benefits under the federal employees health benefits program; administrative services only products, such as medical claims administration, pharmacy benefits management, and utilization management and quality assurance programs; consumer-directed benefit options comprising health reimbursement accounts and health savings accounts to commercial customers; and comprehensive health benefits on a risk basis to members participating in the Medicare Advantage Coordinated Care Plans and Medicaid programs. Its Specialized Managed Care includes Medicare Part D program that provides access to prescription drug coverage for eligible beneficiaries; network rental business that offers network rental services through a national PPO network to national, regional, and local third-party administrators, as well as insurance carriers; and behavioral health benefits business provides coordination of comprehensive mental health and substance abuse treatment services. The company’s Workers’ Compensation division offers managed care services, such as

“Case management is a collaborative process of assessment, planning, facilitation, care coordination, evaluation, and advocacy for options and services to meet an individual’s and family’s comprehensive health needs through communication and available resources to promote quality, cost-effective outcomes” (CMSA. p.6, 2010). Case management plans are an integral part that help to develop and contribute to the care and services that will be needed to provide services to the client to achieve optimal health outcomes (CMSA, 2010).

At this particular site I saw the importance of pharmaceutical care and its importance between patient and pharmacist. The major idea of pharmaceutical care is having a patient-centered pharmacy practice. This was practiced heavily at this pharmacy. Patients were counseled on any new prescriptions that they had and they were always informed about any changes in their medications. In my second week of IPPE I had to inform a patient that their medication would look

Companies strive to choose not only the best marketing channels, but also the best profitable channel. A profitable channel can promote and successfully sell out of a product that might not otherwise turn a profit for their producers (New Charter University 2015). “The calculations from the cost accountant for the retail segment accounts were 60 percent of sales, and for the foodservice segment accounts were 40 percent. The cost accountant believes that both channels are profitable. The accountant also believes that the company achieves an overall average gross margin of 60 percent on its sales (Bowersox, D. J., Closs, D. J., Cooper, M. B.,

The Pacific Oil Company a well-established oil company with an assorted diversified product line including “Vinyl Chloride Monomer (VCM)”. (Lewicki, 2010, p. 583) As one of the pioneer producers of VCM, Pacific Oil cornered the market share for contracting, distributing and selling their niche product, VCM worldwide. One of Pacific’s longtime customers was Reliant Corporation. This partnership was more than a decade old and was strong. However, if Pacific Oil decided to further diversify its product line to include Polyvinyl Chloride (PVC) a VCM derivative, “it would not want to be in the position of supplying a product competitor with the raw materials to manufacture the product line, unless the formula price was extremely

Planning system weaknesses: To begin with, fundamental assumptions, such as new plants, inventory carryovers, packaging trends, etc., which are used for initial sales forecast, are entirely made by corporate headquarters. However, the divisional managers assume full responsibility for the estimates they submitted to the corporate head office. As a result, they have to make efforts to increase the overall accuracy of forecast and avoid making changes in subsequent reviews of the budget. Moreover, each product line uses the same forecasting method. It is ineffective for the company to make accurate budget since factors affecting each product line are different, such as industry trends, customer preferences and so on. Lastly, instead of plant managers, the district sale managers raise the sales budgets. However, the plant managers are held accountable for this budgeted profit number, which is connected with their performance and is not controlled by them.