5-1 Discussion: Managed Care Plans Response
Posts
Analyze
the posts rationale and constructively critique the viability of their
recommendations. Based on their support and explanation, would you follow their
recommendation?
Please
respond to each of the 2 posts separately
Post 1 –
5-1 Discussion: Managed
Care Plans
Jisela Colon
Hello Everyone,
Managed-care plans are essential types of
healthcare insurance that help individuals access healthcare services at low
costs, get accredited care services, and cheaper prescriptions. However, the
efficiency of managed care plans differs depending on the type of the managed
care plan. One managed healthcare plan that my organization can adapt is the
Health Maintenance Organization (HMO) managed care plan. HMO is essential
insurance that “is based on a network of hospitals, doctors, and other
healthcare providers who collaborate to coordinate care within a network”
(Franco, Chehal & Adams, 2020). In return, the clients make certain
payments for the services they receive from the network. HMO care
providers are paid depending on the number of members served despite the number
of visits a member receives. The HMO only covers in-network providers, which is
“care received from the plan’s contracted providers. Individuals covered in the
HMO plan need to select their primary care doctor to manage their health care,
and the primary care provider can refer the member to a specialist within the
HMO network” (Giardino & De Jesus, 2020). HMO can give members referrals to
see external specialists for care that cannot be provided within the network.
Finally, members can get emergency services from the nearby emergency room.
Therefore, the organization should adopt this plan because it has numerous
benefits both on members and healthcare facilities than drawbacks.
Some of the benefits of the HMO plan include lower
payments per month and relatively lower out-of-pocket expenditures.
Furthermore, members will enjoy lower out-of-pocket expenditures for
prescriptions. Also, claims need not be filed because members receive medical
care in-network. Finally, individuals enjoy the convenience of having a primary
care doctor who helps advocate and manage care. Nevertheless, the HMO plan has
drawbacks that include staying within the network to get care services unless
it is an emergency service. Another disadvantage is that a member will need to
select a new primary doctor if the primary care doctor is not within the
network (Namburi & Tadi, 2020). Therefore, my organization should adopt the
HMO plan.
References:
Casto, A. (2018). Principles of Healthcare
Reimbursement, Sixth Edition (6th Edition).
Franco M. D., Chehal, P. K., & Adams, E. K. (2020). Medicaid Managed Care’s
Effects on Costs, Access, and Quality: An Update. Annual review of public
health, 41, 537-549. https://www.annualreviews.org/doi/full/10.1146/annurev-publhealth-040119-094345
Giardino, A. P., & De
Jesus, O. (2020). Managed Care. StatPearls [Internet]. https://www.ncbi.nlm.nih.gov/books/NBK564410/
Namburi, N., & Tadi, P.
(2020). Managed Care Economics. https://europepmc.org/books/nbk556053
Post 2
5-1 Discussion: Managed Care Plans
Contains unread posts
Ronda Kovar-Pepper
Classmates and Dr. Roberts,
As a healthcare administrator, I suggest a
modified fee-for-service method since it does not pay for unnecessary, more
expensive, or redundant tests and procedures. The PROMETHEUS (Provider Payment
Reform for Outcomes Margins Evidence Transparency Hassle-reduction Excellence
Understandability and Sustainability) payment model encourages patient
wellness. Since the physicians “receive high bonuses for providing
uncomplicated and efficient care to the patients” (Rajpa, Peruchi, &
Sawhney, 2013, p. n/a), the patients, providers, and organization benefit. Even
though the physicians are paid on a fee-for service method, they are motivated
their bonuses. Thus, by encouraging healthy habits, including preventative care
to the patients, the patient is less likely to return to the Emergency
Department, Urgent Care, or need additional more complex care. Currently,
unfortunately, COVID has created a delay in care which is detrimental to the
patient and the caregiver since they are unable to receive their bonus. For
example, my organization put all physicals and child check-up exams (including
for children) on hold due to COVID. The practices had to prioritize sick
patients over promoting wellness in their patients. The good news is the delay
only lasted for one month, and the organization has resumed the previous
structure. There are issues with all managed care plans, but I consider this
one the most beneficial for payers, patients, and the organization. While
quality care is encouraged, costs are reduced.
Reference
Rajpal, G., Peruchi, R., & Sawhney, R. (2013). Healthcare Reimbursement
Plans:
Methodology, Advantages and Disadvantages. IIE
Annual Conference. Proceedings,
https://www.proquest.com/docview/1471961727/fulltext/9451581B9EF24A9FPQ/1?accountid=3783
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