ESSENTIALS OF MANAGED HEALTH CARE - PART 1: INTRODUCTION TO MANAGED CARE

Course overview

OBJECTIVES SECTION 1: AN OVERVIEW OF MANAGED CARE 1. Identify the managed care steps that employers can take to constrain health care costs and promote wellness. 2. Identify the managed care steps that employers can take to constrain health care costs and promote wellness. 3. Describe three (3) aspects of the maturation of managed care. 4. Describe PPO and POS plans. 5. Describe how the relationship between the government and the managed care industry has changed over the years. 6. Discuss five (5) key issues that will affect the future of managed care SECTION 2: TYPES OF MANAGED CARE ORGANIZATIONS 1. Describe the continuum of managed health care plans and the key differences for each. 2. Describe how managed health care plan model types have changed over the past 5 years and employ reasons that might explain these changes. 3. List the principle elements of control found in each type of managed care plan. 4. Describe the primary strengths and advantages and weaknesses and disadvantages of each type of managed care plan. 5. Describe the differences and similarities between a primary care model PPO and a health maintenance organization POS. SECTION 3: INTEGRATED HEALTH CARE DELIVERY SYSTEMS 1. Describe the key elements of the different types of integrated delivery systems (IDS). 2. For each type of IDS, describe conditions that would make that model preferable over all others. 3. Define physician practice management companies (PPMCs). 4. Describe the conditions under which an HMO would desire to contract with an IDS and describe these conditions for each model type. 5. Explain the conditions under which an HMO would actively avoid contracting with an integrated delivery system; define these conditions for each model type. 6. Discuss strategies used by an advanced-model IDS to improve its chances of success under managed care or under a flexible pricing model. SECTION 4: ELEMENTS OF THE MANAGEMENT CONTROL AND GOVERNANCE STRUCTURE 1. List the eight (8) primary functions of a managed care organization's board of directors. 2. Explain the seven (7) key management positions on the board of directors of a managed care organization. 3. List the seven committees crucial to the successful operation of MCOs. SECTION 5: EXAMINING COMMON ASSERTIONS ABOUT MANAGED CARE 1. Explain why it is important to examine scientific evidence rather than anecdotal evidence when making assertions about managed care. 2. Identify at least four managed care myths and explain why these myths are false. 3. Explain managed care's impact on the cost or affordability of health coverage and the quality of health care delivered. 4. Identify at least three (3) areas in which managed care has improved access to health care services. 5. List three (3) examples of common assertions about managed care's impact on physicians and physician/patient interaction and explain how these assertions are proven false by evidence. OUTLINE SECTION 1: INTRODUCTION TO MANAGED CARE A. INTRODUCTION B. MANAGED CARE: THE EARLY YEARS (PRE-1970) C. THE ADOLESCENT YEARS: 1970 -1985 D. MANAGED CARE COMES OF AGE: 1985 TO THE PRESENT 1. Innovation 2. Maturation 3. Restructuring E. FUTURE ISSUES FACING MANAGED CARE 1. Interplay between the Public and Private Sectors 2. Role of Quality 3. Technology Assessment and the Coverage Determination Process 4. Financing Access for the Uninsured and for Graduate Medical Education F. CONCLUSION SECTION 2: TYPES OF MANAGED CARE ORGANIZATIONS A. TYPES OF MCOs 1. Managed Care and Indemnity Insurance 2. PPOs 3. Exclusive Provider Organizations