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HSM 546 Entire Course Health Ins and Managed Care
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HSM 546 Week 1 Quiz
HSM 546 Week 2 You Decide
HSM 546 Week 3 Quiz
HSM 546 Week 4 Managed Care Enrollment
HSM 546 Week 5 Quiz
HSM 546 Week 6 Executive Summary Article Review
HSM 546 All 7 Weeks Discussions
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HSM 546 All 7 Weeks Discussions
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HSM 546 W1 DQ1 HMO Formation
HSM 546 W1 DQ2 ManagedCare Plans
HSM 546 W2 DQ1 Utilization Management
HSM 546 W2 DQ2 The Effect of Human Behavior
HSM 546 W3 DQ1 Payment Mechanisms
HSM 546 W3 DQ2 ManagedCare Under Writing
HSM 546 W4 DQ1 Consumer Strategy
HSM 546 W4 DQ2 Claims and Benefit Administration
HSM 546 W5 DQ1 Social Insurance Medicaid
HSM 546 W5 DQ2 Social Insurance Medicare
HSM 546 W6 DQ1 The Regulatory Environment and Quality in Managed Care
HSM 546 W6 DQ2 The Quality of Healthcare
HSM 546 W7 DQ1 Issues Driving Federal Policy
HSM 546 W7 DQ2 The Impact of Technology
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HSM 546 Week 1 Quiz
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1.
Question :
(TCO B) The integral components of managed care are _____.
Student Answer:
wellness and prevention
primary-care orientation
utilization management
wellness, prevention, and utilization management
All of the above
2.
Question :
(TCO A) Which organization(s) need a corporate compliance officer (CCO)?
Student Answer:
Health plans with a MedicareAdvantage risk contract
Every organization that provides healthcare.
Hospitals
All of the above
Health plans with a MedicareAdvantage risk contract and hospitals
3.
Question :
(TCO A) Basic elements of credentialing include _____.
Student Answer:
hospital privileges
malpractice history
medical license
continuing medical education (CME)
All of the above
4.
Question :
(TCO B) When selecting a hospital during the network-development phase, an MCO considers the _____.
Student Answer:
occupancy rate
cost of services
scope of services
All of the above
occupancy rate and the scope of services
5.
Question :
(TCO B) Common areas of clinical focus subject to hospital P4P programs include _____.
Student Answer:
community acquired pneumonia
congestive heart failure
acute myocardial infarction
prevention
community acquired pneumonia, congestive heart failure, and acute myocardial infarction only
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HSM 546 Week 2 You Decide
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Scenario Summary:Cooper-Pearson Sports Marketing
Cooper-Pearsonis a very successful sports-marketing company with 75 employees. It has been in existence for 10 years, and it clearly has a bright future. One of the fundamental reasons for Cooper-Pearson’s phenomenal growth has been an investment in selecting the best and brightest men and women from colleges and universities throughout the United States and paying them well. Cooper-Pearson Sports Marketing has noticed that, in the past 2 years, 15 key senior employees have left the firm. Many of these men and women have joined Always on the Ball Sports Marketing Company, a competitor of Cooper-Pearson. During the exit interviews, one of the reasons that was consistently mentioned as a reason for leaving was the lack of adequate or affordable medical insurance.
Cooper-Pearson Sports Marketing managers have come to understand that a competitive compensation package must include medical benefits that employees want and can afford. They also understand that medical insurance has become an important recruitment tool in attracting quality employees. Like the company, quality coverage is extremely important, but so is cost.
Your Role
The company has engaged your services to research several insurance programs. First, compare and contrast the differences between an HMO, a PPO, and an indemnity insurance program. From the list below, select and discuss at least one other important service that Cooper-Pearson should consider when selecting an insurance program.
1. Discuss the importance of managed-care physician credentialing.
2. Explain the benefits of a prescription drug program to the employer and the employee.
3. Explain the importance of quality-management indicators in managed-care programs.
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HSM 546 Week 3 Quiz
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1.
Question :
(TCO D) Capitation will solve the issue(s) of _____.
high-utilization patterns
poor quality of care
lack of accessibility
All of the above
None of the above
2.
Question :
(TCO D) Which of the following is the leading reason for member complaints?
Student Answer:
Lack of coverage
Enrollment issues, such as a missing ID card
Claims issues
Interactions with the member’s PCP
3.
Question :
(TCO D) Discuss how information technology (IT) can make disease-management programs more successful.
Information technology can aid in helping the program by maintain the statistics, schedules, activities for each disease, provide some project management. The technology cn become an essential pat of the by help in monitoring the case time schedules and due dates as well as a quick look at the progress of your project.
Information technology (IT) contributes to disease management (DM) through a number of aspects. The use of data mining to determine patterns of care and the use of predictive modeling are paramount for a successful DM program. Automated decision-support software are also required to enable case managers and others to document interventions, track changes, communicate with other case managers, and have automated access to clinical algorithms. Also, the use of the Internet allows for added means of communication with patients and providers. Automated clinical-sensing devices used by the patient transmit data to DM case managers and allow for better clinical status tracking.
4.
Question :
(TCO D) Which of the following is not necessarily a red flag for case management?
Long hospital length of stay
Expenses beyond a certain threshold
Location of care
Early referral to a specialist
5.
Question :
(TCO D) Which of the following aspects of the claims capability must be counted or measured in order to allocate adequate resources and verify financial assumptions about an insured population?
Inventory receipts
Timely filing limits
Turnaround time, based on the date the MCO received the claim
Claims lag
IBNR
All of the above
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HSM 546 Week 4 Managed Care Enrollment
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Scenario Summary:Managed Care Plan Enrollment
Atlanta, Georgia has a very diverse work force, consisting of men and women of various ages, ethnic groups, skills, and education. Many people live and work in one of approximately 14 counties that make up the Atlanta region. It is not uncommon for an employee to drive close to 100 miles one way to get to work. The employer base is diverse as well, consisting of large and small employers that range from entrepreneurs; healthcare services; local, state, and federal government offices; information technology; higher education; landscaping; personal services; banking; and the fast-food industry. Now that we have some background information, let’s learn more about the ABC Insurance Company located in Atlanta.
The ABC Insurance Company has been very aggressive and quite successful in recruiting companies, organizations, and individuals to join its managed care plans. Their ranges of services and rates have been extremely competitive. Their employer base is spread out among the 14 counties, which has been attractive to many employers. The ABC Insurance Company has been quite successful in selling its managed care insurance program to employers and organizations, so what is the issue?
Verde Greene Hospital has an excellent reputation for quality in maternity care, cardiac rehabilitation, and orthopedic medicine, and it is the only hospital in town to have received the Magnet Award for Excellence in Nursing. A sizable number of employer groups as well as employees, who have insurance coverage with ABC Insurance Company, want Verde Greene Hospital to be included in the network as a participating hospital.
When ABC insurance company approached Verde Greene Hospital to recruit it as a participating provider in their managed care plan, Verde Greene Hospital was very delighted to be asked. In fact, the hospital’s overall response was quite positive. However, there was one contractual stipulation that Verde Greene Hospital needed prior to signing any contracts and becoming a participating provider. Specifically, Verde Greene wanted to be the exclusive provider of maternity and cardiac care for all the patients in the ABC Insurance Company network: no exclusivity, no deal.
Because so many employers had pressured ABC Insurance Company to contract with Verde Greene Hospital, the insurance company agreed to the stipulations and agreed to enroll Verde Greene as a participating provider of care and an exclusive provider of cardiac and maternity services. This contract is legally binding for both parties, and they are scheduled to sign this contract in 10 days.
It appears that the exclusivity clause in the contract may have created several unanticipated problems, which are listed below.
It means that patients who needs cardiac or maternity care may need to drive 50 miles and pass four or five other good hospitals in the plan network in order to get the care they need at Verde Greene Hospital. A number of obstetrics and gynecology physicians, as well as cardiologists, who reside in one of the 14 counties do not have privileges at Verde Greene Hospital and have threaten to disenroll from the plan if Verde Greene Hospital is the only hospital contracted to see their patients. Even if these physicians are given hospital privileges, this would mean more staff meetings and Emergency Department duty at a hospital that is too far away. The existing staff physicians at Verde Greene Hospital object to the loss of available hospital space and time, as well as to the possibility of losing existing patients to the new physicians. These physicians also threaten to disenroll from the plan. The other hospitals in the managed care plan object to the loss of patients and have threatened to disenroll from the plan as well and have threatened to sue for restraint of trade.
Your Assignment
What should ABC Insurance Company do? Why? How? What should Verde Greene Hospital do? Why? How? What should the employers do? Why? How? What should the patients do? Why? How?
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HSM 546 Week 5 Quiz
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1.
Question :
(TCO F) Which of the following payment policies addresses the issue of selection bias among Medicare risk plans?
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ISAR adjustments
Regional benchmarks
Risk adjustment
None of the above
2.
Question :
(TCO F) Which of the following standardized measures for quality of care is commonly used for managed care and Medicare programs?
Student Answer:
HEDIS
TQM
SERVQUOL
QOI
3.
Question :
(TCO F) Which of the following represents the largest group of persons in the Medicaid program?
Student Answer:
Persons who have low income and minor children
Persons who are economically poor and older
Persons who are in nursing homes or in specialized facilities
Persons who are economically poor and disabled
4.
Question :
(TCO F) Outcomes of the TRICARE program suggest that _____.
Student Answer:
cost controls are increased
quality is increased
military reports cards are more favorable
All of the above
5. Question :
(TCO F) Which of the following has been adopted as the new quality initiative within the military health system?
Student Answer:
TQM
Six Sigma
CQI
Balanced Score Card
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HSM 546 Week 6 Executive Summary Article Review
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Article Review
Complete the Week 6 Article Review. The article can be found by clicking on the link provided (Week 6 Article Review) or by looking in Doc Sharing.
MANAGED CARE January 2009 ©MediMedia USA
Cover Story
Disruptive Innovations That Will Change Your Life in Health Care
The innovations that we list here are not unfamiliar, but don’t underestimate them. As they
mature, they will have strong effects.
By Maureen Glabman
Contributing Editor
In 1995, Harvard business school professors Clayton Christensen and Joseph Bower put “disruptive
technologies” in the business lexicon by introducing the term in a seminal article in the school’s journal.
The phrase described what happened in 1960, for example, when an unknown company, Sony, began
selling an affordable transistor television that eventually replaced RCA’s vacuum tube.
Soon it became apparent the transistor alone — the disruptive technology — did not tell the whole
story. To achieve success, the technology had to be……………………………………………………………..
Executive Summary
“A disruptive innovation is an innovation that transforms an existing market or sector–or creates a new one–by introducing simplicity, convenience, accessibility, reliability, and affordability, where before the product or service was complicated,
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