FQHC Strategic Alliance Program

The policy issue that I have selected to discuss herein is the pay-for-performance payment model. I feel that this impacts a large number of our population and changes in this regard should be made. This type of payment model aims to use reimbursement to incentivize providers to deliver high quality services. Pay-for-performance model steps away from the traditional manner of reimbursement of fee-for-service, in which providers receive payment on the basis of frequency or volume of the services they provide regardless of outcomes. In contrast,

It is essential for an administrator to understand how private and government payers impact actual reimbursement. Government payers have a standardized benefit structure. The one benefit is that registration staff have an easier time calculating payment due (copayments) for service and can set up payment arrangements. Since the most significant proportion of funds coming into a healthcare organization is usually payments from third-party payers, therefore, it is critical to know how each reimbursement affect the others that come in. Healthcare organization may have hundreds of different payer’s relationships in the form of different contracts that have their own rates of payment that are usually different from other payers for an identical

As a managed care organization Kaiser Permanente has served as a model for informational healthcare systems and the recent demand for affordable care has prompted the organization to lower cost in services without hindering the quality of care. Kaiser Permanente has integrated a system in which the organization assumes all financial risk and a bundled enrollment fee for service strategy. What makes Kaiser Permanente unique from other HMOs is their accountability for quality, utilization management, financial risk, and business strategies (Kaiser Permanente, 2009).

Healthcare is often driven by consumers and insurance companies; there is strong pushes for insurance companies to start paying better through Patient Care Medical Homes (PCMH) or Accountable Care Organizations (ACO) rather than paying at a per-visit basis (Hamlin, 2015). With PCMH or ACOs payment is made on a continuum of care, encouraging the provider to be involved in all aspects affecting health of the patient (Derksen, & Whelan,

Closing out the meeting was John Connolly who serves as Associate Director of Insure the Uninsured. Connolly detailed the Covered California healthcare exchange as a commercial insurance provider. Connolly spent the majority of his time speaking addressing the improvements to coverage, and eligibility changes to applicable California residents. Making a repeated and substantial effort to state how the commercial insurance exchange would work, Connolly showed the various healthcare providers that would be available to certain individuals, and an estimation of the average cost per provider. The most significant aspect of Connolly’s presentation was his outline of the new health insurance plan tier levels, ranging from “Bronze” to “Platinum”. Bronze tier coverage represented the tier with the smallest amount of payment made by the plan and highest amount of payment made by the consumer, and Platinum tier coverage representing the highest amount of payment made by the plan and lowest amount paid by consumer.

Throughout the early 1980’s and 1990’s the Federal Medicaid program was challenged by rapidly rising Medicaid program costs and an increasing number of uninsured population. One of the primary reasons for the overall increase in healthcare costs is the

When evaluating a provider's location for accessibility, managed care organizations consider the distance between the provider's location and members, as well as geographical barriers. It is not the intent of a managed care organizations to expend long trips to physicians or hospitals for medical care. For each provider type, the organization also examines typical patterns of utilization and average costs for selected services. Baker comments, "Defining a panel offers managed care plans the advantage of selecting providers with whom they are interested in working as well as the potential to obtain some contracting advantages through which they can sometimes obtain discounts from physicians who would like to be included in the panel" (Baker, 2000, p.3).

|Indemnity Plan |Able to choose hospital and doctor, Fee for service, deductible, |Individuals and Families |

“No. Basing the analysis on an issuer’s entire overall book of business expected to be paid for the year or book of business in a specific region or State is not a reasonable method to determine the dollar amount of all plan payments under MHPAEA. To the extent group health plan-specific data is available, each self-insured group health plan must use such data in making their projections. For large fully-insured group health plans, for which the premiums are determined on an experience-rated basis, the issuer should generally have group health plan-specific data to make projections. If a large, fully-insured plan does not have sufficient group health plan-specific data to make projections, data from other similarly-structured group health plans with similar demographics can be utilized for the analysis.

which care is delivered by a specified network of providers who agree to comply with the care

For Shelby and Mark, they are faced with determining what insurance policy will fit their needs now and in the future. With Shelby owning her own business, this health insurance policy will cover both her and Mark, so consideration needs to be given to the health of both individuals. The health care insurance planner sheet will allow them to review the numbers behind both policies to determine what is best for them financially, as well as in the event that one of them should suffer some type of medical crisis. This form will give them the tools to make an informed decision concerning the out of pocket costs for both HMO and a traditional policy. Additionally, should a medical crisis occur that forces either Shelby or Mark into claiming

Other programs under DM that have shown to be beneficial to both the members and the health plans are, shared decision-making programs and medical informatics. PPOs, HMOs and CDHPs have preventive services programs being implemented. Preventive services include services such as: immunizations, mammograms, physicals, and counseling. An independent study on an indemnity plan that had prenatal preventive services showed that members who enrolled into this program had an average of $3200 less per delivery than those who had not (p.194). Health risk appraisals are a program geared to obtain information from members regarding activities or behaviors that can affect their health status (Kongstvedt, 2007,p.193). When the health plan obtains this information it

Marina, I enjoyed reading your post. I think the reason why a person’s age and health affect their premiums is because if a person health is poor, it carries a higher risk (gamble) versus a person in good health. A majority of the insurance company also bases a person’s premium on whether he or she smokes or not. Again, I enjoyed reading your

Plan category: health care plans are available in various categories and these categories reflect the costs of each plan category. Plans will likely have lower premiums and higher out-of-pocket costs or highest premiums and lowest out-of-pocket costs.

Therefore, we can unwittingly keep up soundness in protection trades: If wellbeing designs increment a large number of dollars in premiums by half or all the more, yet the individuals who need to get appropriations have no impact. The truth of the matter is, the individuals who live underneath the neediness line of 25% will dependably bear the impacts of more noteworthy deductibles, however none of the superior increments.