HCM 400 Mastery Exercises

Managed care dominates health care in the United States. It is any health care delivery system that combines the functions of health insurance and the actual delivery of care, where costs and utilization of services are controlled by methods such as gatekeeping, case management, and utilization review. Different types of managed care plans came into development by three major factors. These factors include choice of providers, different ways of arranging the delivery of services, and payment and risk sharing. Types of managed care organizations include Health Maintenance Organizations (HMOs) which consist of five common models that differ according to how the HMO is related to the participating physicians, Preferred Provider Organizations

The Iron triangle for healthcare consists of cost, quality, and access; these three characteristics when balanced create great healthcare. Managed Care Organizations combine the three to offer consumers with care that is appropriate for their individual needs. Our book describes managed care organizations as “the cost management of healthcare services by controlling who the consumer sees and how much the service cost” (Basics of the U.S Healthcare System, Niles). Taking a look at the history prior to the Health Maintenance Organization Act of 1973 (HMO ACT of 1973) the implementation has been significant in balancing cost, and quality control. Before this Act was signed in to law by President Nixon healthcare costs were determined by fee for service. A fee for service or indemnity plan is a plan that allows the provider to determine the cost of service, this fee for service plan caused for healthcare costs to increase rapidly. An example of this would be going to the doctor with neck pain, being told to stretch then receiving a bill for 25,000 dollars. As could be understood the cost of healthcare had became a problem.

Third party – Reimbursement payments made by an insurance company that provides benefits for the

Emergency room over utilization is one of the leading causes of today’s ever increasing healthcare costs. The majority of the patients seen in emergency rooms across the nation are Medicaid recipients, for non-emergent reasons. The federal government initiated Medicaid Managed Care programs to offer better healthcare delivery, adequately compensate providers and reduce healthcare costs. Has Medicaid Managed Care addressed the issues and solved the problem? The answer is ‘Yes’ and ‘No’.

“a) Contracts that explicitly detail the responsibilities of employers as purchasers with insurance, managed care, and hospitals and physician groups as suppliers, b) Information to support the management of purchasing activities, c) Quality management to drive continuous improvement in the process of healthcare purchasing and in the delivery of healthcare services, d) Incentives to encourage and reward consumers, and e) Education to assist employees become better healthcare consumers” (p. 352).

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

Managed care and its competition is being viewed to solve their issue on the struggle to control

The Outpatient Prospective Payment System was developed to control the costs for healthcare services by using a bundled payment system. The Balanced Budget Refinement Act of 1999 mandated other

Describe minutes of therapy that can be billed to Medicare part A and what cannot?

Throughout the nineteenth century, there was scarcely a market for health insurance in the United States. One advantage is that they have experience in other states, particularly

The goal of the HSCEC was to establish a reasonable, equitable, and transparent way to pay for uninsured care (Murray, 2009). This is achieved through fairness, as a politically independent agency, and equity, with all patients paying for their own care, not the care provided to other patients, along with a fair share of hospital cost, to include uncompensated care (Murray, 2009). Regulatory, this required all hospitals and payers to provide timely and accurate data to develop a payment methodology that is consistent with market-based principles and legislative intent (Murray, 2009). As a hybrid strategy, the state receives the benefits of both approaches, legislation that seeks to maximize equity for all, and market based approaches that maximize consumer sovereignty. By offering hospitals financial incentives, while allowing hospitals to be at financial risk for managing operating cost, the system can control cost, but not hospital profits. Payers and hospitals remain motivated to save money by lowering hospital costs, rather than shift those cost to other payers, ultimately leading to the successful achievement of long-term policy goals and the avoidance of major short term disruptions in the delivery system (Murray,

Managed care is the most dominant healthcare delivery system in the United States and available to most Americans. Employers and government are the primary financiers of managed care. The managed care sector includes approximately

The article mentioned two vital elements within a health contract. This would be the payment schedule and the contract language but its importance is not in the given order. For my part, I consider the most critical is the contract language. Health plan contract negotiation can be a primary means to profit enhancement if reasonable rates of payment can be negotiated. This necessitates the participating health care  provider to observe with all bylaws, rules, regulations, policies, and procedures and other pertinent details of the MCO

HMOs multiplied rapidly with the new federal giveaways. Managed care, now including PPOs, mushroomed. Employers initially perceived managed care plans as cheaper than traditional fee-for-service insurance. Gradually, they stopped offering a choice of health plans, making individual policies more expensive. HMOs' penetration of the industry had been subsidized into existence. Government had instituted managed care. Today, while overall quality of patient care remains the best in the world, doctors practice medicine in an increasingly intricate web of rationing and regulations: Physicians are stripped of professional autonomy. As patients wander the maze of managed bureaucracy, costs rise and quality deteriorates. Every American dependent on a third party for health coverage is a potential victim of managed care. And state sponsored management of medicine

Private insurance companies negotiate prices with hospitals and health care providers to confirm what will be paid by the insurer. These negotiations can be taxing as both entities fight for what is most profitable for them. The providers involved with the negotiations are “in network providers” and all others fall into the out of network realm and run the risk of not being reimbursed or being paid a certain amount leaving it up to the consumer to pick up the remaining balance. Managed care provides a system by which the priority of health care is to reduce costs while ensuring that the delivery of quality health care is provided to consumers. The different types of managed care organizations include Health Maintenance Organization (HMO) and Preferred Provider Organization (PPO) and both systems follow different payment methods. HMO’s use capitation or fixed annual payments for each person its exclusive list of providers sees no matter what type of care or how much care is provided and PPO’s, like traditional insurance companies, negotiate rates of payment with providers and members enjoy lower out of pocket costs such as deductibles and copays. With PPO’s, members could choose out of network providers and would pay the difference between the reimbursement rate of the plan and the changes of the