Questions On Risk Sharing Arrangements

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

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

The concept generates images of large healthcare entities managing the administrative protocols of prior authorization or denials to the actual delivery of care through a facility or network of healthcare providers. Hacker and Marmor (1999) described several meanings of the term managed care with the most applicable to the menagerie of forms managed care can take being a combination of the financing and delivery of healthcare services. While this particular study is dated, the authors contend any managed care structure features administrative oversight, patient steerage to a particular provider entity or network and the amount of risk-sharing whether at an individual or group level. These features continue to be true today as organizations explore the benefits offered to employees through managed care structures such as preferred provider organizations, clinically integrated networks, and accountable care organizations. As a healthcare provider, the goal is to provide access to healthcare which is affordable, offers access to providers of choice and engages with providers who provide the highest quality

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.

Managed Care is a complex health care system in which physicians, hospitals, and other healthcare professionals organize in an interrelated system of people and facilities that communicate with one another and work together as a unit, commonly referred to as a network. This network coordinates and arranges health care services and benefits for a specific group of individuals, referred as enrollees, for the purpose of managing costs, quality, and access to health care. The Managed care program may be provided in a variety of settings, such as Health Maintenance Organization (HMO) and Preferred Provider Organization (PPO). In Health Maintenance Organization, the insurance company will only pay for care within the network. The member will pick a primary care provider who coordinates most of their care. Preferred Provider Organization (PPO) usually pays more if the member will get care within the network, but they still pay a portion if the member will go outside. And Point of Service (POS) plans let you choose between an HMO and a PPO each time you need care (Merrick, 2013).

“Managed care embodies an effort by employers, the insurance industry, and some elements of the medical profession to establish priorities and decide who gets what from the health care system.” (JAMA.2001; pg. 285:2622-2628). Manage Care is part of the Health Care system since 1973 is known as the system that finances and delivers health care to individuals enrolled under their plans. Manage care is intended to reduce the unnecessary health care cost in America through a variety of mechanism that includes medical necessity review programs, economic incentives for physicians, beneficiary cost sharing, control of

The three principle parties involved in the U.S. Healthcare system are the consumer, provider and insurer. The provider includes the hospitals, clinics, doctors, nurses and pharmacies that provides a service; the consumer is the individual who receives the medical service and supplies the money; and the insurer is a third party intermediary between the provider and the consumer which accept money from a pool of consumers and reimburse the providers. Like any transaction, there is a certain degree of risk associated for members of the different parties. This risk is based upon variables within the U.S. healthcare model including the method of, and who is reimbursing the providers.

The Innovation Center is the creation of the ACA to test the efficiency of various payment models that can reduce the expenditures under Medicaid, Medicare, or Children’s Health Insurance Program (CHIP), without compromising the quality of care. There are three types of participants in this initiative. First, there are awardees who have got into an Agreement with CMS, and assume financial liability for the expenditures in an episode of care. Next, Episode Initiators, as the name suggests, are those providers who elicit the BPCI care episodes. They are not the risk bearers (unless they serve as an Awardee too), but they play a role in the model by signing an agreement with the Awardees. Last, conveners are those entities who bring a number of healthcare providers together, and act either as Awardees who bear the risk or as Facilitator Conveners who do not get into an Agreement with CMS and bear no

The issue of risk scenario carries immense importance for most of the hospitals that are part of the healthcare setting. However, there is not only one scenario that can affect the hospitals but

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

Assume that you have been approached by a competitor in Mexico to engage in a joint venture. The competitor would provide the classroom facilities (so you would not need to rent classroom space) while your employees would teach the classes. You and the competitor would split the profits. Discuss how your potential return and your risk would change if you pursue the joint venture.

develop a methodology for quantifying risks, or should each situation be addressed individually? Can we have both a quantitative and qualitative risk evaluation system in place at the same time?

Today’s risk management environment is more dynamic than ever. More often, companies are embracing risk management’s undeniable opportunity to improve business results. The emergence of this “true business partner” relationship requires that risk management decisions and processes rely more on strategic planning, rigorous analytical processes, and collaborative internal and external partnerships. Knowing which actions and relationships will drive down your costs of risk demands a deep and comprehensive understanding of the factors that influence it.

Risk allocation is performed as part of the development of the project structure, which takes into account the distribution of responsibilities and risks during the planning, construction, financing and operating phases (Corner, 2006). The aim is to identify an efficient and effective structure that optimises the costs of the project and ensures that the risk occurrences do not damage the project (Delmon, 2009). According to Grimsey and Lewis (2007) risk allocation has two elements: optimal risk management and value for money. The first implies that the

The operations on a FPSO encounters many hazards or risk to personnel and the environment. Production facilities on the FPSO increases the risk associated with many marine incident.