Managed Care Services Case Study

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.

Partners HealthCare is a non-profit, health system located in Boston that created a data based transformation (Davenport, 2013). It integrated a new system that aligned the participating organizations to cohesively run as one and to help shape the future of the organization. The system didn’t stop there as it was responsible for bettering the patient financing experience and the delivery of healthcare information to other organizations (Davenport, 2013). The initial goal of the organization was making patient care more affordable and accountable by providing integrated, evidence based, patient-oriented care.

Health insurance is important as it allows people to receive health care. However, health insurance providers are not equal, which result in an unequal quality of care. Private health insurance leads to an increase quality of health care. This is show in the article “A National and State Profile of Leading Health Problems and Health Care Quality for US

Health care plans are policies created to aid the patients in accessing medical services in form of insurance to cover the expenses incurred during treatment and hospital care. In analyzing the options given by two major health care plans elaboration will be based on two major insurance schemes namely indemnity insurance plan and Managed Care plan. All these vary yet with a common aim of providing medical services to the patients. In order for the analysis, consideration will be based on the costs and the coverage. These two plans differ in many important ways, more so in regard to how the services are offered, the way to obtain special care and the cost of care after recovery. Despite the diversities, the two care types share many

The HMO’s stress wellness and preventive care, therefore its focus is more on health maintenance rather than just the treatment itself. Because of this, HMO’s offer much richer benefits than the traditional plans. HMO’s have little to no upfront costs in an effort to encourage maintenance, while comprehensive and major medical plans have up-front cost sharing so as to discourage over utilization.

In this country there are numerous concerns about health care economics. Several factors contribute to the increase of health care costs. One area of concern is the impact of managed care on health care finances. Managed care has been around since the early 1970s. The definition of managed care is a set of contractual and management methods implemented to manage the financing and delivery of health care services. Initial implementation of managed care was for health care cost saving (Getzen & Moore, 2007, p. 203, para. 1). Though Managed care initially addressed several health care finance issues, there are still problems with the current

Managed care organizations should have arrangement with both the medical insurers and providers to provide treatment for a contracted rate. Hospital should advertise the services they offer to members of healthcare plans through their healthcare provider by emphasizing on the technology, staff, and other quality of care they provide. Worker compensation plans are similar to commercial plans but treats injured employees. Hospital must contract with all workers compensation plans and must also negotiate coordination of benefits with other insurance carriers of the injured person to full compensate services. For Self pay patients hospital can reach out to them by having pre negotiate rates for treatment when payments are made in advance for certain procedures. Hospital should have system to accept payments when made in any

To conclude this report, there are four considerations of a legal and valid insurance contracts that patients may present at the provider’s office or clinic. The guide to understand and remember are as follows: (a) the patient or person insured must be a mentally competent adult and should not be under the influence of drugs or alcohol; (b) the insurance company must have a signed application and offer the policy to the patient, then the patient or person should accept the issuance of the policy without misrepresentation of facts on the application of the person being insured; (c) the services produced and sold or the exchange of value and the first premium payment should be submitted with the application considered must be presented together; and (d) there should be a legal purpose which is an insurable interest in the case of a person’s healthcare insurance policy. These are good guidelines to know and understand for the success of an administrative life cycle of a physician-based claim (CMS

The book discuss about three major types of managed care organization: health maintenance organizations (HMO), preferred provider organizations(PPO), and point of service plans(POS). Managed care has been around for minute. This organization has been around since 1930s. The three managed care organizations are require an agreement between the insurer and a network of health care providers. Policy holders are encouraged to use the providers in the network by the fact a percentage will pay the cost of care if received outside the network.

The metropolitan classification program is used to determine home mortgage loans, loyalty pay program and varying policies within the Medicare program. The geographic established boundaries of a metropolitan area are representative of that area’s marketplace. Property data collected from the area is reported to bank regulators who will use the data to evaluate lending performance. The data collected could potentially cause bank regulators to consider altering lending practices to suit the area.

For every healthcare organization, contract negotiating is a very important step in the financial strategy, and both parties go through the negotiation process such as research, preparation, cooperation, and settlement to reach an agreement. They are two fundamental factors in this process: revenues and risks, where all organizations wanting to make a profit and in the mean time protecting themselves from any wrong action that could happen in the future. However, “successfully negotiated contracts cannot only preserve revenue but yield additional dollars through new insurance product and models” (hmfa.org). Also, the strong contract provides easier access to all services and result in an increase in the patients’ satisfaction. In addition, “the more an organization solidifies its own expectations for contract negotiating and appreciates the needs of the payers, the more likely it is to reach an acceptable agreement” (hmfa.org). Personally, as a member of the contract negotiating team working on renegotiating a 3-year contract with the Yellow Patriot Health Insurance Company, we have to pay close attention to all terms and conditions and reshape the contract to perfectly fit our organization needs. First of all, we have to choose the best team for this negotiation. Second, demonstrate why we are the best and why it is a gain for the insurance company to pick us. Third, we should request the highest reimbursement. Fourth, we have

Currently, Mark and Shelby have basic health insurance for the both of them. Mark may have the HMO health plan where they have to select their primary care physician and the premium is a descent rate. The couple is young so they would use the plan for annual check-ups for the most part but they will make sure their plan cover maternity. In the further they would need to add their children and change the plan to family coverage. Babies need to go to the doctor’s office all the time for cold, shots, and other minor illness. I think the disability income insurance they select need to be a plan that will begin after 30-days of loss of income due to an accident or illness. This will allow Mark and Shelby to continue paying their bills in the event

One of the must have necessities of a human being is the provision of sound health care and every government, both national or local is obligated to offer this essential service to all the citizens without favor or any discrimination of any kind. Where else it is paramount that every employer to make sure the health and the safety of the employees are given the first priory. This will make sure the employees who are injured during the work are taken care of, and they are relieved the burden of the cost of health care. Thus, it is common to find most companies get the services of insurance companies and other organizations which provide health care programs for workers such as IndUShealth to make sure the welfare of the employees is in safe

Managed care was established in order to manage health care cost, utilization, and quality (Kongstvedt, 2015). In managed care, health insurance is provided through HMO, PPO, and other types of managed care. It has the potential to reduced health care spending and improved the quality of care. However, despite of its success in improving the quality of care through preventive health care services, chronic disease management program, and so forth, many physicians are reluctant to be part of the managed care environment. Some of the reasons are the impact of managed care to physician’s income and autonomy. Under managed care, insurers have decreased the fees paid to physicians. There are different ways how managed care organizations control costs. One of this is through selective contracting with health care providers and hospitals to lower costs. In selective contracting, health care providers agreed to accept lower prices in exchanged for guaranteed volume of patients under managed care plan (Culyer, 2014). This paper will discuss more issues and trends in Managed Care Organizations such as the rise of Medicaid Managed Care spending, the new Medicaid Managed care Rule, and the collaboration of Managed Care Organizations and Accountable Care Organizations to reduce health care spending and improve efficiency of care.

The Fortune 500 company I chose is CVS Health. I chose this for a few different reasons. First, I recently had to visit the Minute Clinic in the CVS store twice within the last month. Secondly, I chose CVS because it is part of the health care initiative and I work for a healthcare company.