Assignment: MANAGED CARE AND ACCOUNTABLE CARE ORGANIZATIONS
Modular Learning Outcomes
Upon successful completion of this module, the student will be able to satisfy the following outcomes:
• Case
o Evaluate and describe key features, differences, disadvantages, and the future of CDHPs, MCOs, HMOs, PPOs, POSs, and ACOs.
• SLP
o Examine rural healthcare delivery and construct a project charter aimed at increasing access to health care services.
• Discussion
o Assess the differences and similarities among MCOs and ACOs and supply a supposition on the future of MCOs and ACOs.
Module Overview
1. What Is a Managed Care Organization (MCO)?
An MCO is a type of health care system that links health insurance with care delivery for a defined population. An MCO delivers health care through a network of providers, determines the prices for services, coordinates care, and manages appropriate use of health care services. One of the goals of the MCO is to provide the highest quality of care within the limits of available resources.
Features of MCOs:
• Members pay premiums and select a primary care physician (PCP).
• PCPs coordinate care for the members.
• A referral is required for specialty care.
• MCOs pay providers directly.
• Members may have small co-pay.
• PCPs are generally paid by capitation (i.e., a risk-adjusted amount per member per month).
To employers, an MCO is an insurer. To providers, an MCO is a payer. To members/patients, an MCO is a service provider.
2. Health Care Organization (HMO) - Closed Panel HMO
Key features:
• Contract with physicians and physician groups on an exclusive basis.
• Physicians do not see patients from other HMOs.
• Patients need to select a PCP and require a referral for specialty care.
• Highest restriction for access. No payment for outside network providers if services are rendered outside of HMO network.
Two Types of HMO:
(a) Staff Model:
• Physicians are salaried employees of HMO.
• HMO owns hospitals and other health care facilities.
• Hospitals and facilities open to HMO members only (in principle).
(b) Group Model:
• Contracts with a single medical group for services.
• Physicians employed by the medical group, not the HMO.
• The medical group practices with the HMO only.
3. Health care Organization (HMO) - Open Panel HMO
Key features:
• Contracts with independent physicians.
• Physicians see patients in the physician's own office.
• Physicians can see patients from other MCOs.
• Patients need to select a PCP and require a referral for specialty care.
Two types of HMO:
(a) Network Model:
• Contracts with multiple medical groups or independent delivery network (IDN).
(b) IPA Model
• Contracts with an independent physician or physician associations.
• Providers paid on a discounted fee schedule or capitation.
• High volume of patients.
4. Preferred Provider Organization (PPO)
Key features:
• Contracts with independent physicians and hospitals as "preferred" network.
• Physicians see patients in the physician's own office and are paid with a negotiated fee.
• Patients do not need a PCP and no referral is needed for specialty care.
• The least restrictive MCO plan.
5. Point of Service (POS)
Key features:
• Between HMO and PPO.
• Members need a PCP and referral for specialty care with HMO benefits.
• Members can go outside of network for services (with a higher deductible and co-payments).
6. What is an ACO?
According to the National Accountable Care Organization Summit (n.d.), ACOs are provider collaborations that support the integration of groups of physicians, hospitals, and other providers in different ways around the opportunity to receive additional payments by achieving continually advancing patient-focused quality targets and demonstrating real reductions in overall spending growth for their defined patient population. The ACO model is highly flexible and can be organized in several ways-ranging from fully integrated delivery systems to networked models within which physicians in small office practices can work effectively together to improve quality, coordinate care, and reduce costs. They can also feature different payment incentives ranging from "one-sided" shared savings within a fee-for-service environment, to a range of limited or substantial capitation arrangements with quality bonuses.
ACOs provide a mechanism to transition from paying for volume and intensity to paying for value. They are compatible with a range of other payment reforms to improve quality, such as medical home and bundled payments; and can help assure that these reforms lead to sustainable quality improvements and cost reductions.
Accountable Care Models
According to Shortell, Casalino, and Fisher (2010), there are at least five different types of practice arrangements that could serve as ACOs: the integrated or organized delivery system, multispecialty group practices, physician-hospital organizations, independent practice associations, and "virtual" physician organizations, all described below.
1. Integrated Delivery Systems
Integrated delivery systems involve a common ownership of hospitals, physician practices, and-in some cases-an insurance plan. Some examples are Kaiser Permanente and Geisinger Health System. These systems typically have aligned financial incentives, electronic health records, team-based care, and resources to support cost-effective care.
2. Multispecialty Group Practices
Multispecialty group practices usually own or have a strong affiliation with a hospital. Examples of this type of arrangement include Mayo Clinic and Cleveland Clinic. They usually do not own a health plan, but rather, have contracts with multiple health plans in their areas. Most have a long history of physician leadership and highly developed mechanisms for providing coordinated clinical care.
3. Physician-Hospital Organizations
These organizations are a subset of the hospital's medical staff. Most were formed in the 1990s in response to managed care pressures to negotiate with health plans. Some function like multispecialty group practices, focusing on reorganizing the delivery of care to achieve more cost-effective coordination. Although they may be less suitable than integrated delivery systems or multispecialty practices to qualify as ACOs, many could structure themselves to meet the criteria for that type of organization.
4. Independent Practice Associations
Independent practice associations consist of individual physician practices that came together largely for purposes of contracting with health plans. Over time, however, many of these have evolved into more organized networks of practices that are actively engaged in practice redesign, quality improvement initiatives, and implementation of electronic health records.
5. Virtual Physician Organizations
A number of small, independent physician practices, many located in rural areas, can organize to become "virtual" physician organizations. This process can be led by individual physicians in rural areas or by a local medical foundation, state Medicaid agency, or similar organization that can provide the leadership, infrastructure, and resources to help small practices develop disease registries; implement electronic health records; share information; and provide better-coordinated, cost-effective care. These virtual networks could qualify as ACOs and serve as models for other groups of small practices.
National Accountable Care Organization Summit. (n.d.). What is an ACO?
Shortell, S. M., Casalino, L. P. & Fisher. E. S. (2010). How the Center for Medicare and Medicaid Innovation Should Test Accountable Care Organizations. Health Affairs, 29 (7), 1293-1298.
Module - Outcomes: CHEMICAL HAZARDS
• Module
o Examine the health implications of chemical hazards in the environment and apply principles of hazard recognition, evaluation, and control of chemical hazards in the workplace.
• Case
o Examine water pollution issues and their human health implications.
• SLP
o Apply principles of hazard recognition, evaluation and control to chemicals in the workplace.
• Discussion
o Analyze implications of persistent chemicals in the environment
Format your assignment according to the following formatting requirements:
1. The answer should be typed, double spaced, using Times New Roman font (size 12), with one-inch margins on all sides.
2. The response also includes a cover page containing the title of the assignment, the student's name, the course title, and the date. The cover page is not included in the required page length.
3. Also include a reference page. The Citations and references should follow APA format. The reference page is not included in the required page length.
Attachment:- Module-SLP.rar