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HCM 500 CSU  Managed Care & Integrated Organizations Discussion

HCM 500 CSU  Managed Care & Integrated Organizations Discussion

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HCM500: The U.S. Healthcare System HCM500: WEEK 6 Paper & Discussion Week 6 Paper: Managed Care and Integrated Organizations Managed Care Payment Mechanisms (90 points) Submit a paper that explores the three primary payment mechanisms used by managed care. For each, discuss how risk is spread between the patient, provider, and managed care organization. Be certain to explore the strengths and weaknesses of each payment mechanism. Submit a paper that explains the role of government in the growth, as well as the decline, of hospitals in the United States. Be sure to discuss major legislation and reimbursement factors. Your paper should be well-written and meet the following requirements: • • • • • 4-5 pages in length (not including cover page & reference page). Robust Introduction: o Open with a robust one-paragraph introduction that provides a brief (3-5 sentences), formal overview of the specific purpose, approach and scope of the paper – provide precise thesis/problem statement. Preview the specific topics, issues, and recommendations that the paper explores. Include at least three references from peer-reviewed articles beyond the text or other course materials. (Not more than 5 years old). Be sure to discuss and reference concepts taken from the assigned textbook reading and relevant research. o Utilize headings to organize the content in your work. Conclusion Week 6: Discussion Post ~ 400 – 500 words Review this article – MACPAC. (2020). Managed care’s effect on outcomes. https://www.macpac.gov/subtopic/managed-cares-effect-on-outcomes/ The prompt is – “While much research has been conducted on whether managed care delivery systems result in better outcomes than traditional fee for service (FFS), there is no definitive conclusion as to whether managed care improves or worsens access to or quality of care for beneficiaries” (MACPAC, 2020, para. 1). Taking an OPPOSING (against) view, address the topic: Managed care delivery, what skills are needed to address managed care effects on patient outcomes, what is the relationship between managed care, access and quality, what metrics are used to measure managed care impact on cost, and what you learned from the article. Use competing facts, data, and assumptions. 400-500 words. Page 1 HCM500: The U.S. Healthcare System References for Paper & Discussion: Case Management Society of America. (n.d.). What is a case manager? www.cmsa.org Cheng, T. C., Lo, C. C., & Womack, B. G. (2019). Working alliances promote desirable outcomes: A study of case management in the state of Alabama in the USA Links to an external site.. British Journal of Social Work, 49(1), 147–162. McDonnell, D., & Graham, C. (2015). Medicaid beneficiaries in California reported less positive experiences when assigned to a managed care plan Links to an external site.. Health Affairs (Project Hope), 34(3), 447–54. Shi, L., & Singh, D. A (2019). Delivering healthcare in America: A systems approach (7th ed.). Jones and Bartlett Publishers. **THIS IS OUR TEXTBOOK** Thompson, S., Whitaker, J., Kohli, R., & Jones, C. (2020). Chronic disease management: How it and analytics create healthcare value through the temporal displacement of care Links to an external site.. MIS Quarterly, 44(1), 227–256. Toseef, M. U., Jensen, G. A., & Tarraf, W. (2020). Medicaid managed care and preventable emergency department visits in the United States Links to an external site.. PLoS ONE, 15(10), 1–15. Page 2 HCM500: The U.S. Healthcare System ***Helpful Resources from this week’s readings for Paper***: Learning Outcomes 1. Describe the links between the development of managed care and earlier organizational forms in the U.S. healthcare delivery system. 2. Discuss the basic components of managed care and how managed care organizations realize cost savings. 3. Examine the driving forces behind organizational integration and strategies commonly used to achieve integration. Learning Outcomes 1. Describe the types of inpatient settings and services. 2. Analyze the factors that contributed to the growth of hospitals prior to the 1980s and subsequent decline in the 1990s. 3. Describe key utilization measures and operational concepts. 4. Compare and contrast the various types and levels of licensure, certification, and accreditation requirements. 1. Role of the Primary Cre Physician as Gatekeeper: In managed care systems, the primary care physician (PCP) serves as the “medical home” for the patient and as the gatekeeper for the managed care organization (MCO). The term gatekeeper is used because many health plans do not allow patients to self-refer. Instead, the PCP must make the referrals to other professionals for consultation and specialty treatment in order to ensure appropriate utilization of non-emergent secondary and tertiary care services. The practice of medicine is built on the sanctity of the relationship between the patient and physician. Physicians have an ethical duty and professional commitment to act in the patient’s best interests. When a PCP detects or suspects a certain illness or disease, the patient may be referred to one or more specialists, such as a cardiologist, oncologist, or a surgeon. In other instances, however, the PCP will treat the patient. For example, if a patient came in with a slight fever and requested a referral to an infectious diseases specialist, the PCP would most likely deny this request and would instead treat the patient himself. Conversely, a patient reporting regular and unresolved problems with heartburn would most likely be referred to a specialist (such as a gastroenterologist) for testing and treatment. In the first example, unnecessary care is not provided, and in the second, the patient is referred for care that is indicated. In each of these examples, the physician maintains professional integrity and ensures that proper care is provided. 2. What Does a Case Manager Do? Case management is the comprehensive process of assessing, evaluating, planning, coordinating, and facilitating the range of services needed to address a patient’s health needs. The overarching goal of case management is to assist an individual in achieving the optimum level of wellness and functional capability in the most efficient and cost-effective manner possible. This does not mean that the Page 3 HCM500: The U.S. Healthcare System patient will be completely cured or returned to some previous, but now unattainable, level of functioning (Shi & Singh, 2019). Case managers (other commonly used titles are care coordinator or discharge planner) are the individuals who help patients reach appropriate and reasonable goals through advocacy, education, and identification of resources, as well as through the coordination of the provision of available services. The work is challenging and demanding. To be successful, they must understand how to work with both the individual patients and their families. They must also possess the critical thinking skills needed to navigate through complex healthcare and social service systems. Click below to view examples of possible responsibilities and settings required of case managers. In general, case managers have a clinical background. Most are either registered nurses or social workers. Many attain the necessary skills through on-the-job training, while others may complete formal coursework. Example 1: For example, a patient with no permanent residence may need a referral to and placement in a homeless shelter at discharge, as well as information regarding public transportation (Shi & Singh, 2019). Example 2: Case managers can be found in different settings, including hospitals, medical groups, insurance companies, and managed care organizations. Thus, in a complex case, a hospitalized patient could have multiple case managers: one that works for the hospital, one that is employed by the physician or medical group, and one from the insurance company. 3. Evidenced Based Medicine It is the practice of physicians, through ordering tests and treatments, that largely determines the financial success of healthcare providers in a managed care environment. There are various methods used to influence the physician decision-making process and behaviors to reduce the cost of care. Click below to explore some of these methods. Utilization Review: The process of examining how resources are used to provide care, and evaluating whether services provided were appropriate (Shi & Singh, 2019). This includes such things as length of stay, discharge disposition, cost of care, etc. Benchmarking: The practice of comparing performance against established standards and “best in class” organizations. Physician Profiling: The process of examining utilization and outcomes data related to a specific physician’s practice. Like utilization review, this includes such things as length of stay, average cost, discharge disposition, etc. Clinical Pathway: Guidelines that specify key aspects of clinical care (such as medications) for a given clinical condition, such as pneumonia or congestive heart failure. Evidence-based medicine (EBM) is another important method used to influence physician decisionmaking. Medical practice is characterized by a high degree of uncertainty; cause and effect relationships are not always clear. Uncertainty arises because the physician may not know everything about the patient that is relevant to diagnosis and treatment. A physician’s preference for diagnostic certainty may incline them to use more tests. When faced with a patient with a particular diagnosis, the physician often has several options to choose from. Physicians must make implicit judgments based on their knowledge, training, and experience. These judgments vary widely and are the primary source of practice variation. One goal of evidence-based medicine programs is to reduce uncertainty and unnecessary variation (CMSA, n.d.). Page 4 HCM500: The U.S. Healthcare System 4. Disease Management Disease management is often used to refer to comprehensive programs or systems used to coordinate multi-disciplinary healthcare services for defined populations with specific conditions (such as congestive heart failure, diabetes, and stroke) across the continuum of care. The programs generally select chronic conditions that account for a large portion of healthcare spending. The goals of such programs are to improve the quality of care, quality of life, and to reduce costs (Shi & Singh, 2019). Disease management programs use tactics to improve physician use of, and patient compliance with, evidence-based medicine guidelines and treatment plans. To be successful, the patient must be a full partner in the program, working closely with the care team. Indeed, a primary tenet on which such programs are built is the idea that patients who are educated about their disease are more motivated to properly manage their health (Shi & Singh, 2019). The most effective programs generally involve numerous healthcare and social service organizations. Thus, coordination and collaboration are essential, but also challenging because organizations may be in direct competition with each other. Thus, many programs are often managed by health plans, insurance companies, or commercial vendors. Further, to ensure collaboration across the continuum, providers are often provided incentives to participate and rewarded when measurable program objectives are achieved. Similarly, plans may use disincentives, such as reduced reimbursement, if providers do not participate or if performance targets are not achieved (Shi & Singh, 2019). Remember, everything that is being covered in this module is related to managed care and its efforts to control healthcare spending. While learning about gatekeepers, case managers, and disease management, remember that the intention is to reduce healthcare spending. Understanding Points: With the growth of managed care, the balance of power in the medical marketplace has swung toward the Demand Side. The purpose of risk sharing with providers is to make providers cost-conscious. Gatekeeping heavily depends on the services of a Disease Consultant. The Staff Model HMO model is likely to provide the greatest control over the practice patterns of physicians. Page 5

    • Participation: RN-to-BSNIn discussions, you, as a student, will interact with your instructor and classmates to explore topics related to the content of this course. You will be graded for the following.
      1. Attendance

      Discussions (graded): Discussions are a critical learning experience in the online classroom. Participation in all discussions is required.

      1. Guidelines and Rubric for Discussions

      PURPOSE: Threaded discussions are designed to promote dialogue between faculty and students, and students and their peers. In the discussions students:

      • Demonstrate understanding of concepts for the week
      • Integrate scholarly resources
      • Engage in meaningful dialogue with classmates
      • Express opinions clearly and logically, in a professional manner

      Participation Requirement: You are required to post a minimum of three (3) times in each graded discussion. These three (3) posts must be on a minimum of two (2) separate days. You must respond to the initial discussion question by 11:59 p.m. MT on Wednesday.

      Participation points: It is expected that you will meet the minimum participation requirement described above. If not:

      • You will receive a 10% point deduction in a thread if your response to the initial question is not posted by 11:59 p.m. MT on Wednesday
      • You will also receive a 10% point deduction in a thread if you do not post at least three (3) times in each thread on at least two (2) separate days.
      1. Threaded Discussion Guiding Principles

      The ideas and beliefs underpinning the threaded discussions (TDs) guide students through engaging dialogues as they achieve the desired learning outcomes/competencies associated with their course in a manner that empowers them to organize, integrate, apply and critically appraise their knowledge to their selected field of practice. The use of TDs provides students with opportunities to contribute level-appropriate knowledge and experience to the topic in a safe, caring, and fluid environment that models professional and social interaction. The TD’s ebb and flow is based upon the composition of student and faculty interaction in the quest for relevant scholarship. Participation in the TDs generates opportunities for students to actively engage in the written ideas of others by carefully reading, researching, reflecting, and responding to the contributions of their peers and course faculty. TDs foster the development of members into a community of learners as they share ideas and inquiries, consider perspectives that may be different from their own, and integrate knowledge from other disciplines.

      1. Participation Guidelines

      You are required to post a minimum of three (3) times in each graded discussion. These three (3) posts must be on a minimum of two (2) separate days. You must respond to the initial discussion question by 11:59 p.m. MT on Wednesday. Discussions for each week close on Sunday at 11:59 p.m. Mountain Time (MT). To receive credit for a week’s discussion, students may begin posting no earlier than the Sunday immediately before each week opens. For courses with Week 8 graded discussions, the threads will close on Wednesday at 11:59 p.m. MT. All discussion requirements must be met by that deadline

      1. Grading Rubric
      2. Click here to ORDER an A++ paper from our Verified MASTERS and DOCTORATE WRITERS:  HCM 500 CSU  Managed Care & Integrated Organizations Discussion

        HCM 500 CSU  Managed Care & Integrated Organizations Discussion

        HCM 500 CSU  Managed Care & Integrated Organizations Discussion

    • Discussion Criteria  A
      Outstanding or highest level of performance 
      Very good or high level of performance
      Competent or satisfactory level of performance
      Poor or failing or unsatisfactory level of performance
      Answers the initial graded threaded discussion question(s)/topic(s), demonstrating knowledge and understanding of concepts for the week.
      16 points
      Addresses all aspects of the initial discussion question(s) applying experiences, knowledge, and understanding regarding all weekly concepts.

      16 points

      Addresses most aspects of the initial discussion question(s) applying experiences, knowledge, and understanding of most of the weekly concepts.

      14 points

      Addresses some aspects of the initial discussion question(s) applying experiences, knowledge, and understanding of some of the weekly concepts.

      12 points

      Minimally addresses the initial discussion question(s) or does not address the initial question(s).

      0 points

      Integrates evidence to support discussion. Sources are credited.*
      ( APA format not required)
      12 points
      Integrates evidence to support your discussion from:

      • assigned readings** OR online lessons, AND
      • at least one outside scholarly source.***

      Sources are credited.*

      12 points

      Integrates evidence to support discussion from:

      • assigned readings OR online lesson.

      Sources are credited.*

      10 points

      Integrates evidence to support discussion only from an outside source with no mention of assigned reading or lesson.

      Sources are credited.*

      9 points

      Does not integrate any evidence.

      0 points

      Engages in meaningful dialogue with classmates or instructor before the end of the week.
      14 points
      Responds to a classmate and/or instructor’s post furthering the dialogue by providing more information and clarification, thereby adding much depth to the discussion.

      14 points

      Responds to a classmate and/or instructor furthering the dialogue by adding some depth to the discussion.

      12 points

      Responds to a classmate and/or instructor but does not further the discussion.

      10 points

      No response post to another student or instructor.

      0 points

      Communicates in a professional manner.
      8 points
      Presents information using clear and concise language in an organized manner (minimal errors in English grammar, spelling, syntax, and punctuation).

      8 points

      Presents information in an organized manner (few errors in English grammar, spelling, syntax, and punctuation).

      7 points

      Presents information using understandable language but is somewhat disorganized (some errors in English grammar, spelling, syntax, and punctuation).

      6 points

      Presents information that is not clear, logical, professional or organized to the point that the reader has difficulty understanding the message (numerous errors in English grammar, spelling, syntax, and/or punctuation).

      0 points

      Response to initial question: Responds to initial discussion question(s) by
      Wednesday, 11:59 p.m. M.T.
      0 points lost

      Student posts an answer to the initial discussion question(s) by Wednesday, 11:59 p . m. MT.

      -5 points

      Student does not post an answer to the initial discussion question(s) by Wednesday, 11:59 p . m. MT.

      Total posts: Participates in the discussion thread at least three times on at least two different days.
      0 points lost

      Posts in the discussion at least three times AND on two different days.

      -5 points

      Posts fewer than three times OR does not participate on at least two different days.

      * Credited means stating where the information came from (specific article, text, or lesson). Examples: Our text discusses…. The information from our lesson states…, Smith (2010) claimed that…, Mary Manners (personal communication, November 17, 2011)…. APA formatting is not required.
      ** Assigned readings are those listed on the syllabus or assignments page as required reading. This may include text readings, required articles, or required websites.
      *** Scholarly source – per the APA Guidelines in Course Resources, only scholarly sources should be used in assignments. These include peer reviewed publications, government reports, or sources written by a professional or scholar in the field. Wikipedia, Wikis, .com website or blogs should not be used as anyone can add to these. For the discussions, reputable internet sources such as websites by government agencies (URL ends in .gov) and respected organizations (often ends in .org) can be counted as scholarly sources. Outside sources do not include assigned required readings.
      NOTE: A zero is the lowest score that a student can be assign 

      Read also: HCM 440 Discussion: Ethical Breaches in Healthcare Research

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