HSM340 Course Discussions Week 7


HSM340 Course Discussions Week 7
We know that there is an impact on reimbursement, especially after the Affordable Care Act was…

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HSM340 Course Discussions Week 7

HSM340 Course Discussions Week 7

All Students Posts 65 Pages 

HMO, MCO and Health Plans – 38 Pages 

Discuss legal and regulatory issues that affect MCOs. Negotiations with HMO’s are important but they can also be challenging. It is all about proper business and clinical management working together. There are also a lot of legal and regulatory aspects that need to be watched and monitored. Doctors and hospitals need to work together more than ever before.

Will the new healthcare system change things?  It is all about negotiations and competition. Sometimes are satisfied and sometimes they are not very happy. It is all about negotiations. Do you see the new healthcare system changing things in this area? How is that going to take shape? We know that there is an impact on reimbursement, especially after the Affordable Care Act was passed.

Do we see the MCO role changing as a result? Comprehensive network organization and proper alignment is very crucial here. Quality is gaining more visibility and importance. What do you see as the challenges for MCO’s and their organization?

The mid 1990’s saw a backlash against managed care as they were the dominant paradigm for health care benefits. Patients and providers were frustrated against managed care unnecessary and onerous restrictions with delays and denials due to their cost containment strategy features of employers health benefit plans.
This created a flood of legislation particularly at state level, regulatory and also political proposals designed for changes. Many class actions and lawsuits seek to assign accountability to health plans especially to adverse outcomes that changed health benefit plans and treatment decisions. An example is plan members cannot be dropped from health coverage due to a pre-existing condition or no one should be refused emergency medical service because of an inability to pay (and information about billing should not be posted anywhere or discussed in the ER department). Also patients have the right to consent on treatment decisions and who shares their information. HMO’s were forced to be less restrictive and the practice of defensive medicine so as not to be sued but this lead to increased costs and higher premiums for patients.
The main legal and regulatory issues MCOs faced are:
Benefits Coverage-Medicare Reform, Medicaid, HIPAA Portability, State benefit mandates, the Uninsured, Prescription drug coverage
Patient Protection-Privacy, Access to care and Health plan liability, summary of benefits
Physicians Rights-Physician contracting, state prompt payment legislation, physician antitrust exemption legislation, incentive payments, intentional torts.
Plan Protection and Administration-Risk based capital requirements, health plan solvency, HIPAA administration simplification…

Financial Policy – 27 Pages 

Describe the relationship between financial planning and strategic planning. We all heard of financial and strategic planning. How are these two similar and how they are different? How do healthcare entities engage in these types of planning aspects and how are they affected over the short and long-run?

If there is no ability to raise capital, should financial plans be scrapped? Are there other alternatives? What type of correction plan do you see a healthcare entity adapting to improve performance? What methods do you see healthcare firms adopt to raise capital?

Strategic planning is a systematic and organized process where an organization creates a set of decision making criteria of the way it plans to progress from its current situation to the desired future situation. These decisions are implemented to definitely and permanently guides its operation activities and its structures. In other words it defines the roadmap and actions required for change by generating its vision of how they wish the organization should be in the future. Healthcare organization has to align their strategy to treat customers who will be a growing population, better informed, aware of their rights, demanding quality care, the capacity to chose their health provider and will affect the financial planning of an health care organization. Focus is shifting from a  product aspect to a service aspect where quality customer experience and satisfaction is obtaining the best results. Focus is also on  limited resources and increasing professional and  skilled competitors face increasing complexity of our growing health population.
Financial planning is assessing the financial feasibility of these desired set of strategic programs and services,  review prior financial statements for the past three to five years, define growth needs and may cause a redefinition of an organizations goals. These two are integrated as one cannot work without the other but financial planning is usually preceded by strategic planning for example, a hospital may plan to focus as a specialty hospital but is this financially feasible, will it serve its purpose, will it be profitable, how much of capital expenditure will this take? What are its long term projections and its debt policy based on financing whether by debt or with equity? Key financial ratio should be done so that it can determined the success or failure of a financial plan…

HSM340 Course Discussions Week 7