Managed Care Organizations and Integrated Health Care Networks

Managed Care Organizations and Integrated Health Care NetworksName: Course: Instructor: Date: 1. Discuss risk management's role in managed care organizations (MCOs). The role of risk management is to identify risks inherent in managed care organizations, and hence limit financial losses and injuries, patients, visitors and employees. However, the healthcare sector is ever evolving, with laws, new regulatory frameworks, and regulations placing increased risks on risk managers in identifying and mitigating risks. Thus, the management has the obligation to provide quality health care as this would reduce costs, risk exposure of lawsuits, but will also increase patient satisfaction. Explain the patients' conflict regarding an MCO and the family physician MCOs and physicians need to be cost effective, but this may bring conflicts with patients because physicians may typically spend lest time with patients. In essence, physicians result to spend less time on evaluating patients’ in order to cut on costs. A conflict arises in the physical patient relationship as both have different perspectives on the appropriate visit length time. Health insurance policies may lead to conflicts physician patient conflicts as cost implications are at times a disincentive to physicians. Define MCO. A managed care organization is a network of health care providers for providing quality health care at a low cost. These organizations came into being after integration of business models in the health care to improve on efficiency. Through coordinated efforts, MCOs provide health care, but patients typically choose their physicians among those available in the network. An MCO goes beyond primary health care provision as patients may be referred to specialists within the network unlike traditional healthcare organizations. Discuss the types of MCOs. There are no clear guidelines on categorizing managed care organizations, but differences arise in care plans providers. Preferred provider organizations (PPO) refer to entities that cater for health insurances for employees among a pool of participating providers. Point of service (POS) are a mix of other plans where members can seek the servicers of providers outside the plan if necessary (Kongstvedt, 2007). Exclusive provider organizations (EPO) allow members to receive services solely from providers under these plans (Kongstvedt, 2007). Discuss the regulatory statutes regarding MCOs. Various States in America have different laws that govern managed care, but all aim to protect patients, with most of acts legislated in the years1992-2002. Consumer protections also extends to benefits under insurance policies including the selected benefit mandates under Alabama law Ala. Code § 27-1-10.1 (1997) of 1997 (ILRU, 2004). In Arizona, managed care organizations need to disclose material information pertaining to penalties or incentives from health care providers under Ariz. Rev. Stat. Ann. § 20-1076(A)(6) (West 1997) (ILRU, 2004). 6. Explain the future resolution of conflict between MCOs and risk management. There is a need to resolve conflicts in risk management as this has a direct bearing on physician patient relationship. Thus, managed care organizations ought to emphasize that it is the role of physicians to improve patient satisfaction, through education and adoption of policies in the healthcare sector. Professional values provide a framework for physicians to assess their performance in relation to patient satisfact...