CONSIDERATIONS – Class 10

1. From the four perspectives of (1) employer group, (2) HMO/insurer, (3) provider (physician, hospital), and (4) patient: list the advantages and disadvantages of managed care. Then list for each of these four perspectives, any laws (if any) in regards to managed care that you believe Congress should pass regarding such perspective and give your reason why.

2. Congress passed legislation allowing physicians to create provider sponsored organizations. Should these Provider Sponsored Organizations (“PSOs) be regulated like an insurance company.

– If yes, why.

– If no, why not.

Consider:

These PSOs are a legal entity created by physicians and hospitals to sell medical services under terms and conditions as determined by the PSO. The services may be sold directly to employer groups, cutting out the middleman such as HMO’s and PPO’s, subject to compliance with the law.

An insurance company is generally regulated by the applicable state’s department of insurance and typically have various requirements. These requirements tend to include specifying certain types of benefits required to be provided by the insurance company, requiring the insurance company to maintain certain guaranty funds to cover potential bankruptcies and unpaid claims, and specifying particular grievance procedures.

3. Give examples of healthcare fraud and abuse type of situations and discuss why these type of situations would be against the law. Explore the public policy involved in creating healthcare fraud and abuse type of laws.

4. Analyze the advantages and disadvantages of the self-referral law (“Stark laws”) regarding the statute that curbs Medicare and Medicaid physician referrals to entities in which the doctors or their immediate family members have a financial interest.

5. Differentiate health care delivery systems of other countries.

a) What aspects of the health care delivery systems in Britain, Germany, and Canada have you seen incorporated into the United States managed care system?

b) What aspects of Britain, Germany, and Canada health care delivery systems do you think will become incorporated into the United States managed care system within the next five years and what aspects of the health care delivery systems in the United States will become incorporated into these countries?

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