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Medical Practice Strategies:  Systems Based Practice - Business Laws Ethics

Janet Lerman, J.D.

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CME Test - Class 9
Relevant terms
Models
Employers
MCOs/ Insurers
Providers
Patients
Considerations
Required Readings
Suggested Readings
New News Class 9

 

For CME Test - Class 9 - Click Here

Class Description - Class 9

PERSPECTIVES REGARDING SYSTEMS-BASED CARE:            (1) EMPLOYER GROUPS; (2) MANAGED CARE ORGANIZATIONS/ INSURERS; (3) PROVIDERS; AND (4) PATIENTS 

This class explores the systems-based care organization and employer perspective regarding systems-based care. It is important to understand the employer perspective because it was the employer who typically bought or offered the health insurance benefits to its employees and their dependents. The MCOís set the guidelines for all of the other things covered in the previous chapters. This class will examine four different modes for paying for U.S. health care, employer perspective, and three stages of managed care.

Class 9 Topics:    PERSPECTIVES:     (1) EMPLOYER GROUPS; (2) MANAGED CARE ORGANIZATIONS/ INSURERS; (3) PROVIDERS; AND (4) PATIENTS PERSPECTIVES REGARDING MANAGED CARE

I. FOUR MODES FOR PAYING FOR HEALTHCARE

A.    OUT OF POCKET PAYMENT

B.    INDIVIDUAL PRIVATE INSURANCE

C.    EMPLOYMENT BASED PRIVATE INSURANCE

D.    GOVERNMENT FINANCING

II. EMPLOYER GROUPíS PERSPECTIVE

A.    HEALTH SAVINGS ACCOUNTS

B.    EMPLOYERS MAY CUT BENEFITS OR RAISE

        EMPLOYEES SHARE OF COSTS

C.    WELLNESS PROGRAMS

III. MANAGED CARE ORGANIZATIONíS/ INSURERíS PERSPECTIVE

A.     Managed Care Organizations (MCOs)

        PROFITABILITY

B.    CARVE-OUTS

C.    ACCREDITATION

D.    Liability Issues- Suing HMOs

IV.  PROVIDER'S PERSPECTIVE

    A.    Telemedicine

    B.    Unions

    C.    Patient Relationships

    D.    Medical Malpractice Issues

    D.    Need for Flexible Beds for Aging "Baby Boomers"

    C.    Auditing Managed Care Contracts and

        Relationships

V.  PATIENT'S PERSPECTIVE

    A.    Smart Patients/ Internet Educated

    B.    Patient's Rights

    C.    Aging Baby Boomers Issues

    D.    Alternative Care Providers

Key Objectives

1. Distinguish various basic modes for paying for health care.

2. Examine systems-based practice from an employerís perspective.

3. Examine systems-based practice from perspective of insurers or managed care organizations (such as HMOs or PPOs) creating/offering health insurance benefits.

Review 

1.    List four basic modes of paying for health care and list one disadvantage created by each such financing mode.

2.    List three major factors large company employers will look at in selecting which providers they will contract with to render care to their employees.

3.    Analyze the status of systems-based practice in the United States.  Also, describe the evolution of pricing policies as it applies to physicians, hospitals, and employer groups.

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