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PERSPECTIVES REGARDING MANAGED CARE: (1) EMPLOYER GROUPS; (2) MANAGED CARE ORGANIZATIONS/ INSURERS; (3) PROVIDERS; AND (4) PATIENTS
This class explores the managed care organization and employer perspective regarding managed care. It is important to understand the employer perspective because it is the employer who typically buys or offers the health insurance benefits to its employees and their dependents. The MCO’s 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 GROUP’S PERSPECTIVE
A. HEALTH SAVINGS ACCOUNTS
B. EMPLOYERS MAY CUT BENEFITS OR RAISE
EMPLOYEES SHARE OF COSTS
C. WELLNESS PROGRAMS
III. MANAGED CARE ORGANIZATION’S/ INSURER’S PERSPECTIVE
A. Managed Care Organizations (MCOs)
PROFITABILITY
B. CARVE-OUTS
C. ACCREDITATION
D. Liability Issues- Suing HMOs
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
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 managed care from an employer’s perspective.
3. Examine managed care from MCO’s perspective.
Review
1. List four basic modes of paying for health care and list one problem created by each such financing mode.
See: Thomas Bodenheimer, M.D., MPH. and Kevin Grumbach, M.D., "Paying for Health Care," The Journal of the American Medical Association "JAMA" (August 24/31, 1994): pages 634 - 639.
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.
See: Roger Battistella, Ph.D. and David Burchfield, Ph.D., "The Future of Employment-Based Health Insurance," Journal of Healthcare Management 45:1 (January/ February, 2000): 46 - 57. Sally Berger and Susan K. Sudman, "Giving Employers What They Want," Healthcare Executive (July/August, 1993): pages 12 - 15.
3. Analyze the status of managed care in the United States. Also, describe the evolution of HMO’s pricing policies as it applies to physicians, hospitals, and employer groups.
See: Geoffrey E. Harris, Matthes J. Ripperger and Howard G.S. Horn, "Managed Care at a Crossroads," Health Affairs (January/February, 2000): 157 - 163. Ed Egger, "How Technology is Changing the Health Care System," Health Care Strategic Management (January, 2000): 1, 20 - 23. Frank Cerne, "Cash Kings," Hospitals & Health Networks (April 5, 1995): 51- 52.