1. List three functions of a primary care physician in a managed care system.
  2. In your opinion, is the gatekeeper system effective in controlling healthcare costs and rendering quality care.
    • If yes, why.
    • If no, why not.
  3. Describe the evolution of provider reimbursement and how it affects PCPs.
  4. List advantages and disadvantages of: capitation and fee-for-service.
  5. Describe the purpose of “carve-outs”.
  6. Explain the purpose of risk-sharing pools.
  7. List five questions primary care physicians should ask to help decide if they should join a certain provider network.
  8. How can you keep quality of care if you are paid capitation or discounted fees that don’t cover your costs to provide good care?
  9. Are doctors being forced to do a cost analysis under managed care?
    • Consider: Drug therapy vs. Surgery.
    • Describe what you would do if there was a conflict of interest between what is best for your patient and what is most economical to provide.
  10. Balance the roles of patient advocate and appropriate resource allocators, even if those roles seem to conflict.
  11. What can a primary care physician, contracted with an HMO, do if there is a continued pattern of the HMO omitting that physician’s name from the HMO’s list of contracted Primary Care Physicians? 
    • What if the physician notifies the HMO numerous time of this omission and the HMO continues leaving the physician’s name off of the HMO roster? 
    • What recourses does the physician have? 
    • Would it be helpful for that physician to understand the inner workings of the HMO? 
    • Consider: contractual provisions that might be helpful to the physician. 
    • Consider: if the state has any patient protection laws requiring health plans to provide their members with a complete list of contracted providers and if there are any penalties under this law for noncompliance by health plans. 
    • Consider: if the state has any type of “Any Willing Provider” legislation that may be helpful.
  12. Examine the following scenario:  A small group of primary care physicians employs an additional physician to join their practice.  The small group of physicians have a contract with a health plan entered into prior to the addition of the newly employed physician.  The health plan is not agreeing to add the newly employed physician to the network of contracted providers of the health plan, claiming that it is “full”.  Accordingly, members of the health plan would be out of plan if they were to see this newly employed physician. 
    • What can the medical group do? 
    • Consider: are there any type of laws, such as any willing provider laws, or patient protection type of laws applicable in the state that might be helpful to the physicians. 
    • What recourse can the physicians take? 
    • Consider: what provisions, if any are in the provider contract between the group of physicians and the health plan; and consider what type of provision should be in the contract to protect the  group of physicians.

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