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Mc connell pp_ch26

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  • 1. Umiker's Management Skills for the New Health Care Supervisor, Fifth Edition Charles McConnell
  • 2. Chapter 26 Managed Care
  • 3. Managed Care
    • The principal form of managed care organization is the health maintenance organization (HMO). HMOs were created as a result of the HMO Act of 1973.
  • 4. Managed Care Focus
    • Since its inception managed care has been focused significantly on cost control. The continuing question has been, “Can costs be reduced without adversely affecting the quality and availability of services?”
  • 5. Managed Care Features
    • Complex organizational arrangements between institutions and clinicians
    • Explicit financial incentives for providers and enrollees
    • Defined access to the physician panels and other services
  • 6. Managed Care Features
    • Strong controls on the use of services, especially health care specialists
    • Coordination and integration of services
    • Accountability for an enrolled population and for quality of care
  • 7. Capitation Reimbursement
    • One special feature of managed care is capitation reimbursement, a prospectively determined payment system.
    • This approach transfers financial risk from the insurer to the provider based on some anticipated level of activity
  • 8. The “Gatekeeper”
    • A significant feature of all managed care plans is the use of the primary care physician as “gatekeeper” to the health care system.
  • 9. Other Managed Care Plans
    • In addition HMS, there are:
    • independent practice associations (IPAs),
    • preferred provider organizations (PPOs),
    • point-of-service (POS) plans,
    • physician–hospital organizations, and
    • physician management companies.
  • 10. Managed Care Challenge
    • The principal challenge of managed care is to ensure that every plan delivers high-quality service at an affordable price to all enrollees.
  • 11. Additional Challenging Factors
    • Today’s patients show less trust and less respect for care providers than patients of an earlier generation.
    • Care providers are more stressed; under-staffing is common.
    • Work units are forced to adjust to frequent organizational changes.
  • 12. Additional Challenging Factors
    • Reengineering,” and other such reorganizing activities have reduced job security.
    • Increased errors are seen by some as a problem.
    • Reductions of space and budgets may restrict services.
    • Rapidly growing regulatory bureaucracies.
  • 13. Provider Strategies
    • For health care institutions, especially hospitals, successfully surviving the transition to managed care requires a blend of well-timed and coordinated strategies.
  • 14. Clinical Pathways
    • Written templates of expected interventions and outcomes for selected groups of patients. These allow health systems to standardize care and to improve the processes and outcomes of care where possible.
  • 15. Patient Focus Care Model
    • A health care delivery structure that streamlines care by restructuring hospitals into delivery units that are more self-sufficient. This type of system provides care to each patient by using fewer providers.
  • 16. Benchmarking
    • Clinical benchmarking in which physician practice patterns are matched.
    • Operational benchmarking, which compares organizations from the standpoint of staff productivity, staffing mix, and the use of space and resources.
  • 17. Needed Education
    • Manager and supervisors need educational programs on the subject of managed care. Management should provide supervisors with training in developing budgets that reflect clinical realities, cost accounting, and strategic planning.
  • 18. Survival Competencies
    • Clinical management: resource allocation, productivity measurement, disease management
    • Financial management: budgeting, management of variance, cost analysis, statistics
  • 19. Survival Competencies
    • Information management: communication flow, medical records, quality ­improvement
    • Leadership: personnel management, communication skill, team building, time management .
  • 20. Employment Flexibility
    • Many employers are looking for multidisciplinary professionals, managers, and supervisors to replace highly specialized personnel in certain settings
  • 21. Managed Care Positions
    • Case Managers
    • Utilization Reviewers
    • Advice Nurses
    • Authorizing Authorities
    • Marketing and Sales Agents
    • Claims and Benefits Administration Personnel
    • Actuarial Service Personnel

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