Week 1 Part 1:?Comparing Health Plans? Health insurance can protect individuals from unexpecte ...
Week 1 Part 1:?Comparing Health Plans? Health insurance can protect individuals from unexpected, high medical costs. In exchange for the payments of insurance premiums, the payer (insurance company) is responsible for paying some or most of the costs of medical services. The payer bears the risk for medical expenses, which is subject to cost sharing and coverage limitations. In Part 1 of your initial post,? Select a managed care plan such as a health maintenance organization (HMO), preferred provider organization (PPO), point-of-service (POS), or exclusive provider organization (EPO). Discuss the features, advantages, and disadvantages of your selected managed care plan. Explain the main features of a consumer-directed health plan (CDHP). Assume the role of the decision-maker looking for a health plan for your family, Select one of the plans among HMO, PPO, POS, EPO, or CDHP. Be sure to include a real-life health plan (e.g., Cigna 2000 Choice with a health savings account) that could be the health plan offered by your employer. Discuss the rationales of your selected plan in terms of (a) covered benefits, (b) choice of providers, and (c) level of cost sharing. Part 2:?Managed Care Trends The intent of controlling health care costs has promoted the development of managed care organizations (MCOs) in the past few decades. On the other hand, there have been several legislations enacted to contain health care costs and facilitate the growth of managed care. Managed care is a complex system organized to manage cost, quality, and utilization for delivering and financing health care. Managed care has three main aims: improve health care quality, reduce health care costs, and increase access to health care. In Part 2 of your initial post,? Examine how the Patient Protection and Affordable Care Act of 2010 has impacted health plans in terms of quality, cost, and access. Analyze the current and future trends of managed care in the context of health care reforms. Your initial post (Parts 1 and 2) should be at least 500 words. Support your response with a minimum of two scholarly sources published in the last 5 years. Week 2 The U.S. health care system has been criticized for high cost, inefficacy, and issues with quality. Public and private payers have attempted to utilize various payment methodologies to change providers’ behaviors so that higher quality of care with lower costs can be expected. Pay for performance (P4P) is an approach used to offer incentives to health care providers and organizations to achieve improved performance by increasing the quality of care and reducing costs. For this discussion, you are taking on the role of a director of managed care contracts at the Franciscan Hospital. Your CEO asks you to hold a seminar for the newly hired employees. In your initial post, Explain four provider payment methods: (a) fee-for-service, (b) capitation, (c) global capitation or global payment, and (d) bundled payment. Select one provider payment method from the above as the mainstream provider payment, and compose a detailed account of the benefits and risks from the health care providers’ perspectives. Evaluate the impacts of P4P on provider payment reform brought by the Affordable Care Act. Appraise the health care providers’ reactions to value-based payments. Your initial post should be at least 500 words. Support your response with a minimum of two scholarly sources published in the last 5 years. Week 3 Utilization management helps health care organizations control costs and improve quality. The principal objective of utilization management is the reduction of practice variations by establishing parameters for cost-effective use of health care resources. For this discussion, you are taking on the role of the director of utilization management at Mount St. Clare Medical Center. Some practice variations have been observed among health care providers at your medical center. Your CEO asks you to conduct training for your health care providers. In your initial post, Differentiate three basic components of utilization management as depicted in Figure 5.1 in Chapter 5 of your textbook. Explain the importance of drug utilization review and step therapy. Distinguish between disease management (DM) and case management. Examine a successful DM program (e.g., Aetna Health Connections disease management program) from real-life provided by an employer, hospital, health insurer, or other entity. Be sure to address its accreditation or certification status, if any, and its impacts on health care quality and cost. Your initial post should be at least 500 words. Support your response with a minimum of two scholarly sources published in the last 5 years. Week 4 For this discussion forum, you are taking on the role of the human resources director in a large health system. Your CEO is unhappy with the current health insurance company due to their poor member services and claim processes. You are tasked to find another company that provides excellent member services and timely claim processes. Your benefits consultant, who represents several insurance companies, is on Family and Medical Leave (FMLA) for 2 months. You decide to search online and locate a top-rated health insurance company (e.g., UnitedHealth, Aetna, etc.). Using the health insurance company that you found, compile the critical information about what they offer to make an informed choice. In your initial post, Describe the member services of the health insurance company you found online (e.g., UnitedHealth or Aetna). Discuss current or upcoming technology that benefits plan members. Examine the member’s outreach program and incentives for wellness and prevention. Identify its accreditation or certification, and its commitment to excellence and quality. Generate at least one suggestion to improve the company’s member services or website. Your initial post should be at least 500 words. Support your response with a minimum of two credible sources published in the last 5 years. Week 5 Medicare is a federal government health insurance program that mandates compliance with its standards through state and federal oversights. One of the core Medicare regulations is to protect its recipients. The Balanced Budget Act of 1997 formalized Medicare health maintenance organization (HMO) and named it as Medicare+Choice. Later, the Medicare Modernization Act of 2003 renamed it as Medicare Advantage. In your initial post, Describe federal or state regulations of Medicare Advantage plans. Outline two pieces of vital information regarding Medicare Advantage plans from the Kaiser Family Foundation’s https://www.kff.org/medicare/ webpage. Your initial post should be at least 300 words. Support your response with a minimum of two credible sources published in the last 5 years Week 6 The federal government has increasingly overseen the insurance industry over the past few decades. Congress and federal regulatory agencies have played a considerable role in how managed care is provided. The laws are evolving and expanding. On the other hand, states have a broad range of control of managed care organizations. The main goals of the states are to protect the interest of the consumer and regulate the structure of managed care organizations (MCOs). Based on the first letter of your last name, read your assigned law and respond to the directives. Your initial post should be at least 350 words. Support your response with a minimum of two credible sources published in the last 5 years S = Read the Patient Protection and Affordable Care Act (PPACA). In your initial post, Summarize your assigned federal law governing managed care and insurance market. Describe its impacts on individuals, employers, and payers. Identify two state laws regulating MCOs and health insurers.
