Order DescriptionNo references needed. Please label them by
parts just like it is here.
Part 1
1. I am interested in your ideas on how managed care
organizations can more effectively prevent diseases or more
specifically preventing the spread of disease among its contracted
population. In other words what can HMOs do to promote health and
reduce illness rather than treating it after the fact. Address cost
implications patient receptivity provider cooperation and other
factors impacting this issue.
2. One of the cornerstones of Accountable Care Organizations
is the use of Evidence-Based Medicine. What is this what are the
negatives of EBM and how can HMOs encourage the positive benefits
of EBM.
3. The Health Care Industry has espoused quality management
for decades. Please identify and briefly discuss three quality
management processes at whatever level you wish (insurance
companies hospitals medical groups nursing homes etc.).
Part 2
1. Years ago it was quite common for HMOs to offer a wide
range of behavioral health services including in-patient
hospitalization. More recently HMOs have limited in-patient
programs and encouraged out-patient services. Discuss some of the
reasons for this shift.
2. One of the benefits to patients joining an HMO is the
relatively strict peer-review and physician credentialing process
required for accreditation. Discuss why the credentialing process
is important and how it relates to quality management.
3. Discuss how managed care organizations design market and
sell their products to consumers including individuals and
companies.
4. Years ago when I worked for an HMO is Arizona we
contracted with a private company to provide our HMO with hospital
discharge and cost data by physician specialty. We used this data
to contract with the more cost effective physicians in the State.
In effect we were provider profiling. What are some of the
potential negatives with using this type of data in the provider
contracting process
Part 3
1. In an attempt to improve quality in managed care a report
called HEDIS was established and expanded upon over the years. What
is HEDIS and what is its proported value to health care
2. One of the most important documents established between a
contracted medical group and an HMO is a DOFR (Division of
Financial Responsibility). Discuss the DOFR and identify three
reasons why this document is important.
3. The American Recovery and Reinvestment Act of 2009
included a provision to establish the HITECH Act (Health
Information Technology for Economic and Clinical Health Act).
Identify and discuss three provisions of this Act.
4. Identify and discuss three basic ways to ensure the
accuracy of claims processing within managed care.
Part 4
1. ACA requires HMOs to achieve a certain medical loss ratio.
What is a medical loss ratio and why is this an important issue
2. After the passage of Medicare the federal government has
played a major role in setting health policy. Identify and briefly
discuss three federal laws regulating health care which have had a
material impact on HMOs and the health care industry in general.
3. Over a dozen years ago California established the
Department of Managed Health Care one of the first in the nation to
recognize that HMOs were different from other forms of health care
insurance. Please identify and discuss three major functions of
this Department.
4. Incurred But Not Reported (IBNR) in claims processing can
(and has) led to insolvency on the part of some medical group.
Discuss IBNR and identify several ways capitated medical groups try
to address this issue.
5. There are two basic methods HMOs (and other insurance
companies) use to rate the risk of providing insurance to
employers: experience rating and community rating. Briefly discuss
each method and explain the merits and problems associated with
each method.
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