Discussion Topic- Concepts of Managed Care
In this week’s forum, consider the following:
You are the President of a small area hospital. A managed care plan is moving to town and your hospital has become part of the plans network. In this Discussion Feed, discuss the impact this situation is likely to have on your hospitals financial health, patient volume, and workforce/staffing.
At Least 175 words.
This assignment maps to Learning Objectives:LO2 and LO3
Course Materials :Required Textbooks:Kongstvedt, P., Health Insurance and Managed Care: What They Are and How TheyWork, 5th. Edition. Sudbury, MA: Jones and Bartlett.ISBN- 978-1-284-15209-8 or EBook-ISBN-978-1-284-09487-9
Examples of Specialized Hospitals
Hospital for Special Surgery :https://www.hss.edu/
BlythedaleChildren’s Hospital :https://www.blythedale.org/
Memorial Sloan Kettering : https://www.mskcc.org/about
CHAPTER 3 LECTURE NOTES
NETWORK MANAGEMENT AND REIMBURSEMENT
I. HOSPITALS AND AMBULATORY FACILITIES
A. Reimbursement Methods there are many reimbursement
methods available when contracting with hospitals. In deciding
which method to use, management must have the internal ability to
manage these financial terms in their information systems and
maintenance will be affected to some degree by the types of health
plans that the hospital or ambulatory facility chooses to contract
Types of Facilities and Contracting Situations
Community-based Single Acute Care Hospitals
Physician-Owned Single-Specialty Hospitals
Ambulatory Surgical Centers and Other Ambulatory Facilities
Radiation Oncology Centers
Retail Health Clinics
Urgent Care Centers
II. Credentialing of Hospitals and Ambulatory Facilities
Facilities meeting applicable state licensure and accreditation
standards, as well as participation with Medicare and Medicaid.
Payers do not credential Hospitals and Ambulatory Facilities the
same way that they credential physicians
Individual states typically carry out inspections and initial
evaluations of new facilities, after which they accept
accreditation by recognized facility accreditation organizations
In some cases, a health plan will establish further criteria that
are applicable to certain types of care such are:
o Minimum # cardiac bypass operations performed each
o % patients who achieve the defined outcomes following
o Staffing ratios of nurses and physicians for an intensive
o Center of Excellence
III. Integrated Delivery Systems (IDS)
A. Types of IDSs
Independent and Hospital-Employed Physicians
Management Services Organizations (MSOs)
Patient Centered Medical Homes
Accountable Care Organizations (ACOs)
A term coined by the MedPAC, adopted by CMS, and
incorporated into the ACA
Similar to a Patient-Centered Medical Home (PCMH) in that it
focuses on patients with significant chronic conditions and high
May different types of provider organizations may be eligible for
designation as ACOs. But can be structured like an IDS
CMS (Centers for Medicare and Medicaid Services) requires
ACOs to meet other standards in governance, management,
Must also have 5000 traditional Medicare beneficiaries
assigned to it by CMS
ACOs contract with CMS for the traditional FFS Medicare
Program and are subject to a specific payment model called
B. Vertical Integration
The future of the healthcare sector in the U.S.??
IV. Ancillary Services
Broadly divided into diagnostics and therapeutic services
Diagnostic: Lab, X-ray, CT scan, MRI, EKG
Therapeutic: Home Care, Rehab (Physical,
Occupational, and/or Speech therapies), cardiac, etc .
Can be provided by free-standing facilities although can also be
provided by hospitals
Ancillary services are typically elective and non-urgent
Pharmacy Services are a special form of ancillary service
Contracting for Ancillary Services
V. Network Maintenance
An important function for any payer
o Recruitment and credentialing of new providers
o Measurement and management of the performance of the
o Resolution of claims or other problems
o Visits to each provider at least once or twice a year
o Management of providers who are performing poorly, either
financially or clinically
o 2-way communication b/n network providers and health plan
An MCOs network of providers is its vehicle for providing health care
to its members at an affordable cost.
The composition of the network is directly dependent on the type of
benefits plans being administered and has a direct bearing on the
MCOs ability to manage the cost and quality of the care provided.
Contractual terms between the providers and the MCO are a hallmark
of managed care.
The maintenance of a network requires just as much work as does the
original creation of the network.
Reimbursement of providers is an integral part of the overall
management of utilization and quality of clinical services
Managing quality and utilization effectively is essential for achieving
positive results; reimbursement schemes alone will never be enough.
CHAPTER 3 LECTURE NOTES
Completing a resource and refence
CRAAP Test worksheet on a scholarly article on a nonprofit that services children
C.R.A.A.P. Test Worksheet
The CRAAP Test* is a list of questions to help you evaluate the information you find. Select a source appropriate to your research topic. Use that source to answer the questions below to determine if it is appropriate to use.
Provide an MLA/APA citation for your source here:
What type of source is it?
Magazine Newspaper Book Website
the timeliness of the information
When was the information published or posted?
Is it recent enough to be relevant to your capstone project?
Why or why not
* Websites Only: How recently has the website been
the importance of the information for your needs
Does the information relate to your topic or answer your question?
Is the information at an appropriate level?
Would you be comfortable using this source for a research paper?
the source of the information
Who is the creator or author?
What are the authors credentials or organizational affiliations?
What are the authors qualifications to write on this topic?
*Websites Only: does the URL reveal anything about the author or source? (examples: .com, .edu, .gov, .org, .net)
the reliability, truthfulness, and correctness of the content
Is the information supported by evidence?
Are there citations or a bibliography included?
Are there spelling, grammar, or other typographical errors?
*Websites Only: Do all the links work?
the reason the information exists
Do the creator(s) make their intentions or purpose clear?
Does the point of view appear objective and impartial?
Are there any political, ideological, cultural, religious, or personal bias?
Is the creator/author trying to sell you something?
*The CRAAP Test was developed by California State University, Chico