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6 Cards in this Set

  • Front
  • Back
BACKGROUND
IPA’s (Independent Practice Associations)
 Large physician / specialist groups
 Capitated by the MCO
 Independent corporation
IDS’s (Integrated Delivery Systems)
 very large group, including PCP’s, SCP’s, hospitals, and ancillary providers
 well-capitalized and able to withstand risk
CONSIDERATIONS FOR AN MCO IN RECRUITING SPECIALISTS (SCP’S)
 Location
 the over/under-utilizedness of the provider
 affects ease of recruiting
 the desired patient satisfaction
 Access Needs of members:
 driving time
 Specialist-to-PCP ratio
 Specialist-to-Member ratio

 Number of SCP’s to Recruit
Few:
 Easier UM; better negotiating leverage
 But patients have poor access.
Many:
 HMO plan more marketable; good access
 But hard to manage; higher utilization

 PCP vs. SCP Designation
 Allow phys to choose to be a PCP or SCP but not both.
 Review the phys's practice to designate him properly.
 PCP vs. SCP Cost
 PCP's are more cost-efficient for routine medical care
 SCP's are more cost-efficient at handling serious or chronic conditions.
CONSIDERATIONS FOR AN MCO IN RECRUITING HOSPITALS
Selecting Which Hospitals to approach
 Location and Availability: Rural areas have limited choice
 How many to contract with?
 Same tradeoff as before (few/many).
 Services the hosp offers
 Does hospital have a well-run IDS?
 Is hospital a supporter of the MCO?

 The Market that the hospital is in
Low Managed Care penetration:
 Hospitals are at low occupancy and high profit margins
 MCO can negotiate a good discount from fee-for-service.

High Managed Care penetration:
 Can't get discounted fee-for-service.
 Therefore, use Per Diem or Capitation instead.
 Hospitals more accepting of risk-sharing
 Hospitals and MCO work together as business partners

 The hospital’s data:
 capacity; % of capacity
 Number of bed days the MCO currently has in this hospital
 How much business is shiftable
 The hospital’s outpatient charges
Reasons to Renegotiate a Contract with a Hospital:
 if MCO is expanding
 Consolidation of two MCO’s or two Hospitals
 annually, in general.
 If the MCO can negotiate better discounts now (better reputation)
The Roles of the MCO Plan Manager and the Hospital’s Manager in Negotiation
Roles of MCO Managers
 Executive Director: initiate contact; meet with Exec Dir of hospital
 Finance Director: negotiation; explain MCO’s #’s and business plans
 Medical Director: evaluate quality of hospital; convince them that it can shift members.

Roles of Hospital’s Managers
 Executive Director: set overall strategy
 Finance Director: analyze revenues; capitation adequacy; hospital’s ability to handle new business
 Medical Director: Credentialing, UM, QM

Done.