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OVERVIEW OF Systems Based Practice
This class will give a general history of managed care, why it’s growing in the United States and look at some terms commonly used in managed care. Also, this class will identify four perspectives in which to analyze managed care: (1) Employer groups/Payor, (2) Managed Care Organizations (MCOs) such as Health Maintenance Organizations (HMOs)/ Preferred Provider Organizations (PPOs), (3) Providers (the term "providers" is an all inclusive term for providers of medical care including physicians, hospitals and others), and (4) Patients. A fifth perspective encompassing these four perspectives will be added later in this course. This fifth perspective is Laws and Public Policies, that encompasses all of the previously listed perspectives. The "Relevant Terms" section is an aide defining terms commonly used in the managed care industry to help make sense of the "alphabet soup" terminology used in managed care.
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Managed care is dynamic. New laws on a local, state and federal level are continually in the making, the managed care market is changing with various mergers, acquisitions, bankruptcies, and start-up managed care companies. This course gives physicians and other healthcare providers a framework for analyzing how managed care affects providers.
Class 1 Topics: OVERVIEW OF Systems Based Practice
I. BRIEF HISTORY OF Systems Based Practice
II. WHAT IS Systems Based Practice
III. REASONS MANAGED CARE CONTINUES TO GROW IN THE UNITED STATES
IV. WHAT MANAGED CARE MEANS TO PROVIDERS
V. CONTRAST HEALTH MAINTENANCE ORGANIZATION ("HMO") AND PREFERRED PROVIDER ORGANIZATION ("PPO")VI. EVOLUTION OF HEALTH CARE PAYMENT METHODS
VII. PERSPECTIVESA. FEE-FOR-SERVICE
B. DISCOUNTED FEE-FOR-SERVICE
C. CAPITATION
D. PAY FOR PERFORMANCE
Key Objectives
 | 1. Summarize history of systems based practice. |
| 2. Examine specific terms used in the managed care industry. |
| 3. Identify how managed care effects the following groups: (1) Employer Group, (2) Managed Care Organization (HMO)/Insurer, (3) Provider (Physician, Hospital, Other), (4) Patient. |
Review
| 1. Analyze the current status of managed care in the United States, such as how has managed care changed over the years from the 1980s to now, including what elements of managed care still exist and continue to grow and what elements of managed care are vanishing. Also, include in the analysis, how managed care is effecting hospitals, physicians, and other healthcare providers. |
See: Ken Terry, "Where’s Managed Care Headed?," Medical Economics (April 10, 2000): 244 - 260. Deanna Bellandi, "Natural Selection," Modern Healthcare (February 7, 2000): 30 - 33. George Anders, "The Outlook for HMOs," Frontline Online. Modern Physician, "Growing Pains; Aggressive Business Strategy, Higher Costs Hurt HMOs," (March 1, 2000).
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| 2. Define/compare and contrast: Health Maintenance Organization ("HMO"), Preferred Provider Organization ("PPO"), Independent Practice Association ("IPA"), Third Party Administrator ("TPA"), Capitation and Fee-for-Service. |
See: Joy M. Grossman, "Health Plan Competition in Local Markets," HSR: Health Services Research 35:1 Part I (April, 2000): 17 -35. Relevant Terms.
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| 3. Describe how managed care effects the following groups: (1) Employer Group, (2) Managed Care Organization (HMO)/Insurer, (3) Provider (Physician, Hospital, Other), (4) Patient. |
See: Ken Terry, "Where’s Managed Care Headed?," Medical Economics (April 10, 2000): 244 - 260. Deanna Bellandi, "Natural Selection," Modern Healthcare (February 7, 2000): 30 - 33.