PUBHLTH 1 Lecture Notes - Lecture 78: Preferred Provider Organization, Health Maintenance Organization, Managed Care

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mauvemole377

3 Apr 2019

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Notes access to care - access to care is a non-profit primary health care program for low- income uninsured and underinsured people living in suburban cook county or northwest. Chicago. uninsured disparities - over 15% of population is uninsured -fee-for-service could charge higher rates to insured patients, to cover the costs of treating uninsured. Prices again begin to rise, number of uninsured again rose. Aging population - average age of american is rising and that"s why costs are also rising. Malpractice fears - patients demand the best, not sensitive to price. (bill paid by third party; the insurance company pays). Fee-for-service hospitals could charge higher rates to insured patients to cover the costs of treating uninsured. Controlling costs - price controls tried in 1970: limit new facilities and technology. If hospital could cure patient in a shorter time than average it could keep the extra cash. If a longer stay is necessary, the hospital has to pay the additional cost.

Related Questions

If an insurer incorrectly estimates an insured person'spremium

, then the insurer will suffer a financial loss.

can appeal to the state insurance commissioner for asubsidy.

will drop people whose medical expenses exceed theirpremium.

None of the above

Medicare Part B (physician and outpatient services) is financedby

a premium that is 75 percent subsidized by the government and 25percent subsidized by the aged.

a payroll tax on both the employee and the employer.

a premium that is 100 percent subsidized by the government.

both a subsidized premium and a payroll tax

The diagnosis-related group hospital payment system changedhospital incentives by making it more profitable to

employ physicians.

admit sicker Medicare patients.

reduce a patient's length of stay.

charge more for lab tests.

Medicare is difficult to reform because

		pharmaceutical manufacturers benefit from drug sales under PartD.
		senior congressional leaders do not want their Medicare benefitschanged.
		the Medicare population is opposed and have highvoting-participation rates.
		Medicare reform would likely increase the federal deficit.

Medicare is not considered to be a fair redistributive systembecause

Medicare beneficiaries receive large subsidies regardless of howhigh their income is.

low-income Medicare beneficiaries with high out-of-pocketexpenses must enroll in Medicaid.

low-income employees subsidize high-income Medicarebeneficiaries.

All of the above

Substituting an income-related voucher for the current Medicaidsystem would not achieve the following:

		An income-related voucher would eliminate the large differencesbetween states in the percentage of their populations eligible forMedicaid.
		An income-related voucher would reinforce the movement towardMedicaid managed care, with its emphasis on coordinated care andincentives to provide care in less costly settings.
		An income-related voucher would provide employees with anincentive to forego higher pay so that they qualify for the vouchersubsidy.
		An income-related voucher would provide those on Medicaid withan incentive to take higher-paying jobs because they would onlylose part of their voucher subsidy.

Most states have shifted their Medicaid beneficiaries intoprivate Medicaid managed care/HMO plans. What is the advantage tothe state for doing so?

		Medicaid patients are more likely to receive coordinated careand preventive services.
		By paying HMOs a fixed fee per person per month, states are ableto shift their risk for higher expenditures to a managed careplan.
		Medicaid patients are more likely to have access to a physicianwithin the HMO.
		The HMOs have entered the Medicaid market because they believethey can provide the care less expensively and earn a profit.

What are some legitimate ways to spend down one's assets toqualify for Medicaid?

Fixing up one's house, purchasing a new car, or setting up aspecial burial account

Providing financial gifts to one's children

Transferring property to one's children

Setting up special retirement accounts that can be passed on tochildren or relatives after seven years

How is Medicaid administered?

		By each state, but policy is shared with the federalgovernment
		By the federal government and coordinated with the states
		By a joint commission composed of federal and stateappointees
		None of the above

Why were hospitals and physicians willing to participate in anHMO's provider network?

Hospitals and physicians developed excess capacity and werewilling to discount their prices for more patients.

Hospitals and physicians believed that they could reduce medicalcosts by joining together to better manage patient care.

Some states provided hospitals and their employed physicians anincentive to join or start HMOs to serve their Medicaidpatients.

b and c

How did early managed care firms achieve their largestsavings?

		By limiting access to very expensive specialty prescriptiondrugs
		By reducing hospital utilization of its enrollees
		By making enrollees wait long periods to see their primary carephysician
		By limiting enrollees' access to the HMO's specialists

Managed care plans differ according to the restrictiveness oftheir provider network and access to specialists. Which types ofplans are likely to have the lowest premiums?

		Plans that have the largest ratio of primary care physicians tospecialists
		Plans that have the most experience and have been in existencethe longest
		Plans that have the most restrictive/narrow provider network
		Plans that have received the highest quality and outcomemeasures

QUESTION 20

As part of the Affordable Care Act, health insurance exchangeswere established. What have been the most importantcost-containment approaches used by health plans competing forinsurance exchange enrollees?

		Health plans have used very narrow/limited providernetworks.
		Health plans have dramatically reduced access to new medicaltechnology.
		Health plans have included large deductibles and out-of-pocketpayments.
		a and c

blushtermite492


(Please Summerize the work down below, thank you)

Political	Economic
Growing political influences on healthcare advances	Cost of living increases
Global government influence on healthcare cost	Cost of insurance prices
Government control of Medicaid, Medicare funding	Rise of forecasted interest rates
Social/Cultural	Technical or Technology
Increase average age of population	Demand on new medical treatments
Patient expectations increase	Customize treatments
Demographics are in constant change	More advance service facilities
Environmental	Legal
Growing need for green business	Constant change of government drug Regulations
Environmental agenda and community awareness	Consumer laws
	Health and safety regulations



Porters 5 forces of business model

Competitive Rivalry
Growth opportunity for healthcare companies are expected to growing the next few years
Increase in new revolutionary drugs both in and outside of the US

Threat if New Entrants
Strict government regulations
Difficult to keep up due to constant change
Huge startup cost

Substitute Products
Threat of other substituting product and service at lower cost



Bargaining Power of Customers
Generic drugs offered at large discount to consumer
Larger less customized healthcare facility with lower housing costs
Several facilities offering similar services.

Bargaining power of supplier
Medical suppliers have a large pricing power
Bargaining power of physicians and nurses is huge because of large hospital benefits

Swot Analysis

Strengths

Highly trained and capable employees

Market experience

Strong leadership

High level of organizational efficiency

Excellent facilities

Strong commitment to bettering the community

Weaknesses

Increased cost of healthcare could lower our clientele

Limited staff resources

Limited cash flow to hire and train new employees

Lack of resources

Opportunities

Fast growing technology opens new doors for using state of the art equipment to better serve the patients.

Nursing and residential care is one of the fastest growing industries

Aging population

Threats

Uncertainty in political and economic climate causes hesitation for receiving new patients.

Funding constraints

Highly competitive market

Product or Service Analysis

Our services will be used by patients who cannot afford experimental treatments and patients who have been abandoned by the system because hospitals can no longer provide medical assistance. At our facility, we will be able to work with the families and provide them with different payments options, such as low monthly payment plans. Our main goal is to be able to treat the patient at a very affordable cost; however, if any patient does not possess the means to pay for treatment, he or she would not be turned away; our facility will tap into government and private funding to cover treatment cost.

The beauty of this service is that there isnât a charge of any kind to take part in our program because it is completely funded by government grants. Individuals that would take part would more than likely not have the means to pay a monthly deductible. Due to the nature of the business listed as a non-profit agency, there is no way to make a profit of any kind, as it would jeopardize the business in its entirety.

Some of the market factors that create a demand for our services include the need of medical care after having maximized all resources, the number of low income families, and the number of patients facing health issues needed extended medical care.

Opportunities that may derive from this business is the opportunity to expand and open multiple facilities, while extending a helping hand to many more in need. The risk, however, is the unstable funds deriving from grants. This can pose a huge treat to the business, as grants often times come and go and cannot be counted on as a constant income.

After studying the healthcare system and current policies in place, data shows many individuals facing severe health issues usually go untreated and uncared for due to the outrageous cost of medical care. It is devastating to see how often people, especially the elderly, are sent home and forgotten for the mere reason that hospitals and doctors are not willing to care for patients without financial means. In fact, in 2009 Harvard news reported 45,000 annual deaths due to lack of health coverage in the U.S. alone, which is significantly higher than the 18,000 reported by USA Today in 2002.

Financial Analysis

Clermont will be a nonprofit organization, dedicated to help the most needed. To open the facility fully operational we must take in consideration some fixed expenses like the land acquisition, permits, interest, brokers, administration fees, professionals (facility setup), staff, reports (environmental, occupational, fire, FDA), electricity, water, phone, water & sewer , connections, taxes, insurance, management, security, advertising, accountants, food, lawn mowers, bank fees, etc.

The facility will need have a total value of approximately three million dollars, but if we break the price of the land acquisition in to a thirty (30) year mortgage we can star up the business with an investment of approximately $ 233,944.61 USD to cover the first month of operation including all the startup permits and connections. After the first month the fixed expenses will be $184,444.00 USD with the exception of the months were taxes are due; taxes are around $ 43,000.00 USD paid quarterly will increase the tax month (depending on the facility fiscal year) for $ 10,750.00 USD approximately. We will fund all the costs with private and public funding, fundraiser, events, raffles, and most important with the help of the community.

As we mentioned before, Clermont is a nonprofit organization and we will do everything in our power to give the relief to the families in need. No one will be rejected because they do not have the money or the insurance cannot help. No money will be required from patient and every single dollar received will be spent in the patients, and in improving our facility and our service every day.

We believe our financial even breaking point will be a year after we begin operations, and be profitable soon after. There are many patients in need, and with the government and public grants each person will receive the treatment they need, and we will become the hope of many.

PUBHLTH 1 Lecture Notes - Lecture 78: Preferred Provider Organization, Health Maintenance Organization, Managed Care

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