ESSENTIALS OF MANAGED HEALTH CARE - PART 2: THE HEALTH CARE DELIVERY SYSTEM

Course overview

OBJECTIVES SECTION 1: PRIMARY CARE IN MANAGED HEALTH CARE PLANS 1.Describe a typical credentialing process, indicating which steps are required and for which reasons. 2. Identify the pros and cons of contracting with faculty practice plans, and how managed care plan addresses those issues. 3. Name the proactive steps which an open panel HMO can take to improve provider relations. SECTION 2: COMPENSATION OF PRIMARY CARE PHYSICIANS IN MANAGED HEALTH CARE 1. Describe the key elements in most capitation programs in open panel HMOs. 2. List four reasons for plans to capitate and several drawbacks to capitation. 3. Describe a performance-based fee-for-service reimbursement system in open panel HMOs. 4. Review the difference between service risk and financial risk in capitation. 5. Describe how an IPA might operate to lower its risk profile. 6. List the three (3) main problems with the FFS model in managed care. 7. Define churning, upcoding, and unbundling. 8. Describe the market or network environment that would favor using capitation versus FFS, and vice versa. SECTION 3: CONTRACTING AND REIMBURSEMENT OF SPECIALTY PHYSICIANS 1. Describe the key advantages and disadvantages of capitation and fee-for-service when contracting for specialty services in an open panel HMO. 2. Define contact capitation and explain the advantages/disadvantages of that approach. 3. Discuss how an open panel HMO might capitate specialty services when the specialists are not organized into large groups. 4. Define: a. case rates b. bundled case rates, c. global fees and d. flat rates SECTION 4: NEGOTIATING AND CONTRACTING WITH HOSPITALS, INSTITUTIONS, AND ANCILLARY SERVICES 1. Describe the six (6) basic steps involved in developing a hospital network. 2. List and explain twelve (12 ) reimbursement methods available when contracting with hospitals. 3. Describe the key advantages and disadvantages of various reimbursement systems for hospitals from the point of view of: a. a managed care plan, b. by type of plan, c. the hospital 4. Explain when an HMO would choose to use: a. DRGs b. Per diems c. Capitation d. APCs e. FFS 5. Describe the management tools necessary for a hospital to effectively operate in a heavily capitated environment. 6. Describe the best method for controlling costs of ancillary services. 7. List which ancillary services lend themselves to capitation and explain why.