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ELEMENTS OF Systems Based Practice: HOW HEALTH CARE IS MANAGED
This class will examine how health care is managed by insurance entities and managed care organizations. It will give an overview of various components and parameters used by the managed care industry and examine how different methods of compensation affect providers. Also, this class will identify certain business aspects for providers to consider in their medical practice.
Class 2 Topics: ELEMENTS OF Systems Based Practice: HOW HEALTH CARE IS MANAGED
I. COMMON LANGUAGE OF SERVICES PROVIDED
II. COMMON AND COMPARABLE COSTS PER TYPE OF SERVICES PROVIDED
III. PREFERRED PROVIDER ORGANIZATIONS
Key Objectives
 | 1. Examine concepts underlying managed care. |
| 2. Synthesize how the managed care organization payment mechanism effects the provider. |
| 3. Identify business aspects of practice and cost-effective, appropriate, quality care. |
Review
| 1. Describe the managed care components, parameters, and delivery vehicles. |
See: Gloria J. Bazzoli, Ph.D., Robert H. Miller, Ph.D., and Lawton R. Burns, Ph.D., "Capitated Contracting Roles and Relationships in Healthcare," Journal of Healthcare Management, 45:3 (May/June, 2000): 170 - 188.
| 2. Explain the evolution of the method of provider reimbursement. |
See: Thomas Bodenheimer, "California’s Beleaguered Physician Groups - Will They Survive," The New England Journal of Medicine (April 6, 2000): 1064 - 1068. Lisa Scott, "After the Fall; New Tactics Offer Hope for Battered California Physicians," Modern Physician (May 1, 2000).
| 3. Analyze what "risk" means to a provider in managed care. Also, list at least three factors that effect a physician’s financial performance in a HMO contractual arrangement. |
See: Gloria J. Bazzoli, Ph.D., Robert H. Miller, Ph.D., and Lawton R. Burns, Ph.D., "Capitated Contracting Roles and Relationships in Healthcare," Journal of Healthcare Management, 45:3 (May/ June, 2000): 170 - 188. Frances M. Prescott, "Improve - Rather Than Lose - Your Risk-Taking Entity," Healthcare Financial Management (February, 2000): 39 - 41. Joseph M. Kemka, " New Risk Management Paradigm for Managed Care," Healthcare Financial Management (June 2000): 41 - 42.