Health Maintenance Organizations

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Discussion Question 1
Select three common models of managed health care organizations as discussed in Chapter 23. Identify the pros and cons for each chosen model. Give suggestions to strengthen the weaknesses of the chosen models.
These are the three I pick Health Maintenance Organizations, Preferred Provider Organizations,Exclusive Provider Organizations

Health Maintenance Organizations

HMOs are organized healthcare systems that are responsible for both the financing and the delivery of a broad range of comprehensive health services to an enrolled population. HMOs act both as insurer and provider of healthcare services. They charge employers a fixed premium for each subscriber. An independent practice association (IPA)-model HMO provides medical care to its subscribers through contracts it establishes with independent physicians. In a staff-model HMO, the physicians would normally be full-time employees of the HMO. Individuals who subscribe to an HMO are often limited to the panel of physicians who have contracted with the HMO to provide services to its subscribers.

Preferred Provider Organizations

Preferred provider organizations (PPOs) are entities through which employer health benefit plans and health insurance carriers contract to purchase healthcare services for covered beneficiaries from a selected group of participating providers. Most states have specific PPO laws that directly regulate such entities. Common characteristics of PPOs include:

•   Select provider panel

•   Negotiated payment rates

•   Rapid payment terms

•   Utilization management (programs to control the utilization and cost)

•   Consumer choice (allows covered beneficiaries to use non-PPO providers for an additional out-of-pocket charge [point-of-service option])

In PPOs, a payer, such as an insurance company, provides incentives to its enrollees to obtain medical care from a panel of providers with whom the payer has contracted a discounted rate.

Exclusive Provider Organizations

Exclusive provider organizations (EPOs) limit their beneficiaries to participating providers for any healthcare services. EPOs use a gatekeeper approach to authorize non–primary care services. The primary difference between an HMO and an EPO is that the former is regulated under HMO laws and regulations, whereas the latter is regulated under insurance laws and regulations. Characteristics of EPOs include the following:

•   Primary care physicians are reimbursed through capitation payments or other performance-based reimbursement methods.

•   Primary care physicians act as gatekeepers. (Pozgar 514)

Discussion Question 2

Why are organizations encouraged to develop a culture of safety? How can a culture of safety be achieved? How can a culture of safety be assessed? Research and identify an article discussing a healthcare organization e.g. hospital, nursing home, surgery center, patient care facility etc. that has implemented innovative safety operations to reduce corporate risk. Summarize 3-4 main points from your selected article. Cite the article in APA format as part of your post.

Final Paper

Create an ethical code of conduct for those in governance, management, and professional staff for any one of these health care organizations:

  • Acute-care hospital
  • Surgery Center
  • Behavioral Health Center
  • Specialty Hospital
  • Long-Term-Care Facility
  • Out-Patient Center

In a 10 to- 12 page paper (excluding title and reference pages), discuss the following:

  • Brief background of the facility.
  • Organization structure of the facility and duties/ responsibilities of those in management and professional staff.
  • Two possible ethical dilemmas that may be encountered.
  • Ethical standards for those in governance, management, and professional staff.
  • Ways to implement the ethical code of conduct and ensure compliance.
  • Consequences if there is a violation of the code of ethics.

When writing your paper, use 3rd person. Follow APA guidelines.  Use at least eight scholarly and/or peer-reviewed sources that were published within the past five years, a minimum of three of which must be from the Ashford Online Library.  All sources must be cited according to APA style as outlined in the Ashford Writing Center.

Writing the Final Paper
The Final Paper:

  1. Must be 10 to 12 double-spaced pages in length, and formatted according to APA style as outlined in the Ashford Writing Center.
  2. Must include a title page with the following:
    1. Title of paper
    2. Student’s name
    3. Course name and number
    4. Instructor’s name
    5. Date submitted
  3. Must include an introductory paragraph with a succinct thesis statement.
  4. Must address the topic of the paper with critical thought.
  5. Must conclude with a restatement of the thesis and a conclusion paragraph.
  6. Must use at least eight scholarly and/or peer-reviewed sources that were published within the past five years, including a minimum of three from the Ashford Online Library.
  7. Must document all sources in APA style, as outlined in the Ashford Writing Center.
  8. Must include a separate reference page.
 
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