Hsm 546 You Decide 1 Essay

The types of managed care are differentiated by definition, operation, structure, and information needs. `HMOs were the most common type of MCO until commercial insurance companies developed PPOs to compete with HMOs' (Douglas, 2003, p.331). `HMOs are business entities that either arrange for or provide health services to an enrolled population after prepayment of a fixed sum of money, called a premium' (Peden, 1998, p.78). There are three characteristics that an HMO must have. The first is a health care financing and delivery system that provides services for members in a particular geographic area. Second, is ensured access to a complete range of health care services, health maintenance, treatment, and routine checkups. Last, health care must be obtained from voluntary personnel that participate in the HMO. The five HMO models related to the participating physicians are the Staff

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.

In some ethical and legal respects a pregnant woman and her fetus can be considered separate. Both the woman and the fetus are ordinarily affected by the well-being of one another for as long as each of them live. The ethical and legal issues are challenged deeply in cases where the well-being of the fetus and the mother appear to be in conflict. Our society struggles with identifying cases where the pregnant woman’s interests and/or behaviors might put her fetus at risk. Criminal and/or civil commitments should be used to bar pregnant women from exposing their fetuses to risk.

If I were at that hospital clear cut rules would be discussed regarding premature infant deaths along with sensitivity training.  Check points would be set up so that family would not have access to the actual areas where these infants were held after their passing.  A separate room would be set aside to facilitate this type of viewing.

While our understanding has evolved with respect to certain advantages of MCO’s, our understanding of the disadvantages has also grown. This analysis will evaluate the use of MCO’s as a gatekeeper to controlling health care cost and offerings. It will evaluate the advantage MCO’s provide in a rapidly growing market due to the aging of baby boomers. The analysis will evaluate disadvantages that can arise with relying on MCO’s. These disadvantages work against the insurance company forcing a polarizing balance between how much control the MCO should retain over recommendation and provision of services.

However, this option has its limitations that make it difficult for the patients to access health care services in many ways. Since it does not fully cover the medication expenses, some patients may get it difficult to cover the remaining expenses. The indemnity insurance has the set limit in which the policy will cover you. If the hospital bills surpass the set level, expenses will go up and it will be your responsibility to pay the remaining expenses. This coverage will not be relevant since it will not have fulfilled your mission for taking a policy.

Another type of managed care program that was introduced is the Preferred Provider Organization (PPO). A PPO is comprised of a group of physicians, hospitals and other medical service providers who contract with employers, insurance companies or other plan sponsors. The PPO offers discounted pricing to these contracted organizations due to the high volume of business received. PPO’s typically have up-front cost sharing in the form of deductibles and/or co-insurance, which vary depending upon the actual plan chosen.

Physicians were looking for assistance with HMO and PPO insurance companies and rising healthcare cost and PhyCor, Inc. was there to provide the administrative management. PhyCor, Inc. is considered a physician practice management firm, or PPM, that bought out other management firms to become one of the largest firm due to their ability to negotiate managed care contracts. What attracted physicians to PPMs was their ability to “lower cost and increase revenues” (Burns, L.R., Bradley, E.H., & Weiner, B.J., 2011). PhyCor, Inc. was able to merge large physician groups and specialty clinics creating revenue in the millions, and continued to grow. They grew for several years before the values in stock starting falling, unsatisfied physicians, and

Middlefield Hospital has been a great healthcare facility to the Middlefield area. Middlefield Hospital consists of a 450-bed tertiary facility in a major urban area in the Northeast. The hospital is an integrated health system that provides the full array of inpatient and outpatient services. The hospital enjoys a reputation of quality care in the area. In recent years, there are areas of concern that need to be addressed. As I have been assigned the position as the new Chief Executive Officer (CEO) of Middlefield Hospital, I will provide strategies and recommendations needed for implementation to turnaround the hospital into a more positive experience not

Understand own responsibilities, and responsibilities of others, relting to health and safety in the work setting.

After going through the case of Margie Whitson, the dilemma is the fact that Margie is looking to have her pacemaker removed which will in turn would end her life. So far, Margie Whitson has had a rough year and has come to the decision that she wants her pacemaker deactivated because she believes it is delaying her death. Her pacemaker is the only thing keeping her heart beating at this point. But even at that, her doctor, Dr. Vijay, refuses to deactivate it due to the fear of legal action/misunderstandings of the ethical and legal acceptability. Margie Whitson is very determined to have her pacemaker removed so she call for Jane Robison, the social

1.1 - Explain how legislation,frameworks,codes of practice and policies relating to positive behavior support are applied to own working practice?

I am writing to express my sincere appreciation and to thank you for supporting H.R. 6261.

As the Chief Executive Office of Middlefield Hospital, it has been brought to my attention by the Chief Financial Officer that our financial performance has been deteriorating for the past six (6) months. It has also been brought to my attention that the new facility has been admitting more new patients and our admissions have been declining. The number of uninsured patients has increased over this period of time. The management team has identified some other interesting facts that are possibly hurting the reputation of Middlefield Hospital. My determination is that the financial performance of Middlefield Hospital needs to be improved.

Throughout the last half of the 20th century, employers have acted on their own to regulate health costs by requiring employees to join health maintenance organizations (HMOs). More than 100 million Americans are under managed care. However, many patients and doctors complain that HMOs impose too many regulations and sacrifice healthcare quality. HMOs are undergoing a high level of scrutiny due to criticisms that the network is controlling and jeopardizing the healthcare system of the nation.