CONSIDERATIONS – Class 9

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.

2. Role-play the thinking process of an employer group in determining its healthcare benefits program for its employees. Include analyzing how the following effects providers: reduction in health care coverage due to costs involved; implementing wellness programs for employees; and offering Medical Savings Accounts (MSAs) instead of insurance coverage.

3. Analyze the managed care organization perspective in designing new products to offer to employer groups. Consider the advantages and disadvantages of: traditional indemnity coverage, HMOs, PPOs, MSAs, providers direct contracting with employer groups. In this discussion, include analyzing how each effects providers.

4. Synthesize the effectiveness of accreditation in the health care area and examine who is holding whom accountable. Who are the winners and losers of accreditation?

5. Explore the following scenario: You are a specialist (note: this scenario could also apply to PCPs) and you are losing market share (volume of patients) and you have decided to take your specialty (or primary care) services and market them directly to employer groups as part of a wellness package for the employees. You plan to enter into a retainer agreement with various employer groups and be paid an hourly fee per group patient education presentation. You have recommended to the employer group that they attempt to receive a premium reduction from their insurance carriers for offering your program. In the meantime, you are also contacting various insurance companies and MCOs attempting to have them to “buy-in” to your program to certify they will offer a premium reduction to those employer groups that use your program. You hope to develop a strong enough relationship with the insurance companies and MCOs to have them also market your product to employer groups. You figure that you are doing a public service by offering patient education and that this will also be a source of income for you as well as build good well in the community for your practice. In your evaluation of this scenario, analyze what it takes to make it work and what the advantages and drawbacks are.

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