...Today’s Health Care Reform in the United States Tiearia Fariss HCS/235 July 21, 2013 Professor Cyndie Miculan In the United States there has been always a problem with citizens who do not have medical coverage. Health care reform is part of an ongoing debate in the United States. The government has been pondering on many ways that the government could help the United States citizens obtain health care that currently do not carry health care. In March of 2010 the President of the United States Barrack Obama signed into law the proceeding for the Affordable Care Act that would offer health insurance to millions of Americans. The reasoning behind so many citizens not possessing health insurance at the said current time is because of lack of income to help pay for the needed medical coverage. With this new law there are income related subsides that would help individuals afford the need medical coverage at a cost that is affordable to the individual. When deciding on why the Affordable Care Act would be ideal for the United States the government took into consideration the market rules as well as the quality improvement as priorities for health reform. There are definitely some pros and some cons to the new health care reform that...
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...Health Care System Evolution Paper: Managed Care HCS/310 March 12, 2012 Shannon Packard Health Care System Evolution Paper: Managed Care The evolution of the heath care delivery system in the United States has led to the Managed care initiative. “Managed Care emerged at the early 20th century when the United States lacked private and public health insurance” (Rodwin,p. 653, 2010). Managed Care is defined as “any arrangement in which an organization, such as an HMO, another type of Doctor-Hospital network, or an insurance company, act as an intermediate between the person receiving care and the physician (“managed care,” n.d.). Managed care has influenced the current health care system many times over including spurring the creation of HMOs and PPOs. Managed care grew significantly partly in response to physicians and other health care providers charging more and more for services provided in a competition to control the medical market (Rodwin, 2010). These physicians had a serious conflict in interest between trying to sell medical services, in an effort to charge more, and doing what was in the best medical interest for the patient. Managed care has brought about significant change in the way the health care delivery system is handled. Often times, now, a doctor is reimbursed for what is considered, medically necessary, based on a patient’s diagnosis and the normal course of treatment for that diagnosis. They are also reimbursed at a pre-determined rate...
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...The continuum model of health insurance and managed care that best describes an efficient model is an open panel HMO. As Kongstevedt (2009) explains, an open panel HMO has been part of the health maintenance organization program which allows physicians to participate in the HMO program through the support of an independent practice association. A doctor who participates in this program not only is allowed to see HMO patients, but also those who are not HMO members. This option is in contrast to a closed panel HMO, in which the physician is linked directly to an HMO, and is under contract to see only HMO patients that are assigned to that doctor in the organization (p. 64, 65). An open panel HMO was not originally designed for a health maintenance...
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...Financing and Structuring Health Care Nicole Bryant Kevin Williams Health Services Organization and Management HSA 500 Fall 2010 October 31, 2010 1) Identify and describe at least three main types of health insurance in the U.S. The main types of health insurance are voluntary health insurance, social health insurance, and welfare medicine. In voluntary insurance or private health insurance in the United States can be subdivided in to three distinct categories: (1) Blue Cross and Blue Shield, (2) private or commercial insurance companies, and (3) health maintenance organizations. Nowadays, it is common for Blues and commercials to own and operate HMOs and other managed care plans. Social Health Insurance has two major mandatory social health insurance programs: (1) Workers’ Compensation for the costs and pain of suffering job-related accidents, and (2) Medicare for the elderly, disabled, and other special groups. Several states sponsor social insurance programs in the areas of temporary disability (California) or health insurance (Hawaii and Vermont). Workers’ Compensation provides two basic benefits: (1) cash replacement of a portion of wages lost due to disability and (2) payment for all or part of the medical care necessary. Welfare Medicine is a public assistance that is sponsored by a plethora of federal, state, and local government programs, but the most far-reaching program is Medicaid (Title XIX of the Social Security Act). The distinction between...
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...Features of Health Plans Features of Health Plans There are two types of health care plans. Indemnity and managed care. Indemnity plans utilize the fee-for-service approach, which means that the service is rendered before the fee is paid. Indemnity plans are often higher in cost than other insurances have higher deductibles that must be met before the insurance begins to cover some, but not all medical care. Preventive care is not normally covered. Even after the deductible has been met the insured will still need to pay the coinsurance which is usually 20 % of the total bill. Managed care plans (MCPs) are somewhat different, as they combine finance and health care management with the provision of service. Managed care organizations (MCOs) were first established in 1929, and today almost all employees that have insurance are enrolled in an MCP. The most common forms of MCPs are: Health maintenance organizations (HMOs) plans; point of service (POSs) plans; preferred provider organizations (PPOs); and consumer directed health plans (CDHPs). In an HMO there is a network of providers that the insured must go to obtain services; if the insured were to go outside of the network the service would not be covered. Also the patient must choose a primary care physician (PCP) to manage their care. Since many people did not like being told that they could only see certain providers, POS’s and PPO’s were created to compete for those peoples memberships. In a POS plan patients still must...
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...Features of Private Payer and Consumer - Driven Health Plans Mary Davis HCR 230 September 20, 2015 Charlene Carpenter Features of Private Payer and Consumer - Driven Health Plans When it comes to health insurance plans there are many different private payers that include preferred provider organizations (PPO), health maintenance organizations (HMO), group health maintenance organizations, independent practice association (IPA), point of service (POS), Indemnity, and consumer-driven health plan (CDHP). And consumer-driven type accounts are health reimbursement accounts (HRA), and flexible savings accounts (FSA) (Valerius, Bayes, Newby, & Blochowiak, 2014). Preferred Provider Organization PPO is one of three main types of managed-care plans. It is a fee-for service plan that contracts with medical care providers who provide services for discounted fees to enrollees. If these providers have contracted with the plans they are paid more, but if they have not contracted with the plans they are covered at a lesser payment rate ("The Private Health Insurance Market", 2015). Payment of a premium and sometimes copay for visits are required for PPOs. Primary care physicians are not required to oversee patient’s care for a PPO and referrals to specialist are not required. The premium and copay for a PPO plan is much higher compared to an HMO or POS plan. There are many in-network generalists and specialists for members to choose from. Generally, higher copays, and or increased...
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...amount of health coverage is the Indemnity Plan. Indemnity type of health insurances indemnifies the beneficiary from financial costs associated with health care. The main aspect of indemnity health insurance was coverage for illness not necessarily for prevention or wellness. The insurance company would decide the maximum amount of billing charges and the provider was able to bill the beneficiary anything the insurance did not pay for. In some cases, the insurance company would pay the beneficiary and the beneficiary would have the responsibility of paying the provider. On the other side of the spectrum is Health Maintenance Organizations. Health Maintenance Organization is a type of managed care organizations that provides a form of health insurance coverage that is fulfilled in hospitals, doctors, and other providers under contract. HMO is basically having the beneficiary pay for their coverage in advance rather than paying for each health services. Initially, the beneficiary would have to pay a price of a monthly premium and then HMO will offer a range of benefits from preventive care to full coverage. The main difference between HMO and PPO is the freedom of choice. HMO allows you to see doctors only within the HMO’s network but with PPO you can choose to see any doctor you wish but the coverage will result in higher out-of-pocket costs like copays and coinsurance. In the middle, Preferred Provider Organizations (PPO) are contracted between employer health benefit plans...
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...this recommendation you will find a (DCF) discounted cash flow, this will determine whether or not the post-merger company will have the ability to overcome any opposition that be in question. I will also be discussing the proposed strategy that we intend to take, should we agree to the merger. We will explore what works well for each organization and the best way to combine those efforts to maximize on continued growth for the organization. We here at Merck, being the world’s largest drug manufacturer and leader of research and development efforts, have determined that there has been tremendous growth in the area of managed care. Medco is the leading prescriptions benefits Management Company and marketer of mail order pharmaceuticals. It is noted that, experts predict that “90% of Americans will have drug costs included in some kind of managed health care plan, and 60% of all outpatient...
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...Critically discuss: a) Why Cambridge Hospital Community Health Network embarked on the ABC study? There are two main reasons why the Cambridge Hospital Community Health Network (the Network) embarked on the Activity Based Costing (ABC) study. Firstly, the Network needed to gain a better understanding of its unit-of-service costs, which had been rising at a rate of 10% per year. In fact it had recently been rated the third-highest cost hospital in the state of Massachusetts. Being a high cost provider could make the Network uncompetitive for Medicaid and other public contracts. Secondly, the Network’s new operating budget required a $14 million reduction, which represented 15% of the total hospital network’s operating budget, in expenditures during the next two fiscal years. This was largely due to the downward pressure on hospital revenues by the government reform and managed care forced providers to cope with conditions that were constantly changing, while continuing to provide quality health care services in a time of intense competition. The Network's traditional method of analysing costs is the Medicare step-down costing system. It gave little information about the cost at the unit of service level. It gave only aggregate costing information (i.e. information about the departmental or global costs) but it does not provide the costs at the patient or procedure level that is needed in order to push cost reduction and also price their services competitively...
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...Financing and Structuring Health Care Detra Smith Dr. Cynthia Davis HSA 500 October 31, 2011 The three main types of health insurance in the United States are voluntary health insurance, social health insurance, and public welfare health care programs. Voluntary health insurance (VHI) is private insurance made up of Blue Cross and Blue Shield, private or commercial insurance companies, and health maintenance organizations. Private health insurance was a source of financing for personal health care expenditures. It also started as coverage for hospitals and physicians. Social health insurance (SHI) includes workers’ compensation, Medicare, and other special groups. It is an entitlement program. Payroll taxes fund this program. Public welfare health care programs include Medicare, Medicaid, and SCHIP and they funded by federal, state, and local governments. There are guidelines in place for persons eligible for any of these programs. The guidelines also vary from state to state. Millions of Americans use this program. Medicare is used by persons who are 65 and over, disabled, and have end stage renal disease. Medicaid is designed to help the poor, children, and pregnant women who are uninsured, underinsured, or cannot afford health insurance. The three methods for categorizing health insurance in the United States are according to the typical combination of products, by the type of organization sponsoring the coverage, and by the funding mechanisms. Principal...
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...MODULE 2 – ESSAY ANSWERS Chapter 4 In Whose Interest Does the Physician Act? 1. Why do physicians play such a crucial role in the delivery of medical services? Although only 25 percent of personal medical expenditures are for physician services, the physician controls the use of a much larger portion of medical resources. In addition to their own services, physicians determine admission to the hospital, the length of stay once in the hospital, the use of ancillary services and prescription drugs, referrals to specialists, and even the necessity for services in nonhospital settings, such as home care. The role of the physician has been shaped by two important characteristics of the medical system. The first is the legal system: only physicians are permitted to provide certain services. Second, both patients and insurers lack the necessary information to make many medical-related decisions. Patients depend on the physician for diagnosis and recommended treatment and have limited information on the qualifications of the physician or the specialists to whom they are referred. The patient’s lack of information places the physician in a unique relationship to the patient. The physician becomes the patient’s agent. 2. How might a decrease in physician incomes, possibly as a result of an increase in the number of physicians, affect the physician’s role as the patient’s agent? In addition to being the patient’s agent, physicians are suppliers of a service, and their incomes depend...
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...Running Head: FINANCIAL MANAGEMENT Financial Management MGMT 312 Financial Management Businesses must have a plan to succeed; if the original plan is not a success, there must be a few alternative plans available. First, the roles of a financial manager will be discussed. Second, a scenario was given to find a future value during a five year time frame and the results will be discussed. Finally, risk contracting will be evaluated including the various financial incentive structures and how they could be used to improve the efficiency of care in risk contracts. First, the roles of a financial manager will be discussed. As a manger, one is required for “effective risk management” (Farley, 2000). “More desirable options include growth, structuring incentives to reduce or eliminate unnecessary variation in resource use, and capturing information about why variations in resource use occur,” (Farley, 2000). Farley explains that larger organizations have more options than smaller businesses because it allows more room for risks (2000). A financial manager should be capable of strategic planning. Benoff mentions in 2000 that the strategic planning should consider, “a variety of market approaches before settling on a specific future market strategy.” Benoff (2000) strongly believes, “to account for the needs and perspectives of all stakeholders, therefore the strategic –planning...
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...Features of Health Plans University of Phoenix 7/25/2012 HCR/220 Features of Health Plans There are several different major types of healthcare plans available and some of them of different and some of them are similar. Knowing which one is best for you, the consumer, is very important because you want to get the best coverage for your money while making sure it is affordable you. Deductibles and co-pays are a huge part of healthcare plans and you always want to exactly what is covered and what is not. Features of Health Plans There are several different types of healthcare plans available today that can help meet the needs of many different consumers. The types of plans that are available are, Indemnity Plan, Health Maintenance Organization (HMO), Point of Service (POS), Preferred Provider Organization (PPO), and Consumer-Driven Health Plan. Some of these plans are similar in some ways while others are completely different. When you are trying to decide which one is best for you, it is always good to compare them. The Indemnity Plan lets you choose any provider unlike the others where you either have only HMO providers or you have to select a network or out of network provider like you have to with a PPO, POS, and the Consumer-Driven Health plan. With the Indemnity Plan you do have higher costs just like you would with a PPO but you also have deductibles, coinsurance and preventative care is not covered unlike the PPO, HMO, POS, and Consumer-Driven...
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...|Accountable Care Organization (shared savings) |Primary Care Medical Home |Bundled Payment |Partial Capitation |Full Capitation | |Strengths and Weaknesses |-Providers are accountable for total per-capita costs. -Patient “lock-in” is not required. - Reinforced by other reforms that promote coordinated, lower-cost care. |-Supports coordination of care between physicians. -Does not require accountability for total per capita cost |-Promotes efficiency and care coordination. -Does not require accountability for total per capita cost |- Combines FFS and prospective fixed payment, providing “upfront” payments that can be used to improve infrastructure and process. - Accountability only for services/providers. - May be viewed as risky by many providers. |- Provides “upfront” payments for infrastructure and process improvement and makes providers accountable for per-capita costs. - Requires patient “lock-in.” - May be viewed as risky by many providers. | |Strengths for Primary Care |YES - Provides incentive to focus on disease management. - Additional support by adding medical home or partial capitation payments to primary care physicians. |YES – Changes care delivery model for primary care physicians, allowing for better care coordination and disease management |YES, indirectly – Bundled payments result in greater support for primary care physicians |Yes – Partial Capitation allows for infrastructure and process improvement, creating a new model for primary care delivery...
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...dependent on a ventilator for breathing and a feeding tube for nourishment. The accident left her paralyzed and her awareness is uncertain because she communicates by nodding her head. The patient’s physician Dr. Bob Pritchard, who is in charge of Lydia’s care, is not very confident about her recovery. Lydia’s husband, Mr. Bevin, says his wife would not want to be kept alive in this fashion and does not know the location of her advance directives. Unfortunately, Lydia’s mother, Eileen Redfield, believes in miracles and end of life is not an option for her. The battle of emotions between mother and husband has Dr. Pritchard in the middle. Mr. Bevin states that before their marriage Lydia had written an advance directive but he was unable to locate the document. Without knowing her advance directives, it became the responsibility of her love ones to make the final decision about continued care or termination. For someone as critical as Lydia, end of the life decisions are not an option for Lydia’s mom. On the other hand, her husband thinks that Lydia should not have to suffer in this way and agrees to end life. It is not easy for anyone involved and having to make an ethical decision to end life. The end-of-life critical care cases tend to experience the most emotional turmoil, and are the most difficult. The CEO of the hospital, Felicia Larue, has asked for a briefing on the status of the patient and alternative methods to protect the patient’s rights and minimize the hospital’s...
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