MHA Module One: Context of Leadership in the U.S. Health Care System
Scotti, D. J. (2001). Strategic Renegotiation of Managed Care Contracts. Healthcare Financial Management, 55(11), 40.
Renegotiation process on the contract between healthcare financial managers and organizational providers is the key aspect of maintaining the quality of delivery of care services and the terms of myriad revenues and costs. A renegotiation contract is considered as a quality continuous improvement responsibility for the services rendered. Thus, a relationship between Anthem and Orlberg have established the common goal to maintain the quality assurance for primary physicians, specialty physicians, nurse practitioners, patients, stakeholders and other important third party members. As the today’s economic trends have advanced in the area of science and subcategory of scientology studies medical biotechnology and advances in cure medications. Besides, the insurance program have changed their regulation system to ensure that patient receive the maximum benefit of care. Therefore, the point in this discussion is that it is necessary to renegotiate the contract in terms of the relationship with external economic factors. A four-phrase process that guides the composing an effective managed care contract portfolio which contains the first phrase to analysis the external and internal situations then move to the second phrase to assess the contract that seen fit for both Orlberg and Anthem. The third phrase gathers to formulate and implement the contract renegotiation strategies and to establish contract maintenance and monitoring directions as the final 4th phrase of creating an effective managed care contract portfolio. Also, it suggests that Orlberg and Anthem to take into consideration on all aspects of marketing objectives as in terms of geographic coverage, market share, payer mix, and scope of services. It helps to ensure that these key parameters to receive the attention they deserve during the fit-assessment and strategy-formation phases of the contract-renegotiation process.
On the behalf of the Anthem HealthCare of Oregon, we want to express our concerns in regards to the sections of Hospital Service Agreement contract. This is necessary in determination to have (an) additional information on several sections as desired to protect both parties involved in the agreement, not only that the information to be amend to the provisions of the policy are desired, but to have a comprehensive contract that do not leave any potential impositions against the parties involved in the contract.
Furthermore, we offer our strengths, weakness, opportunities, and threats (SWOT) analysis of the contract. This is an intention to exercise the rules, policies, and procedures to dissemble the sectional statement to be ascertain that a word for word is legitimate. For instance, in the administration guidelines, in some sections should be described as to what responsibilities of a party or parties providing such services as ‘delivery of care services’ and how the administration fees, physicians, medical equipments, supplies, and other associated activities are rendered. As such, the services shall be descriptive and defined.
More specifically, we will be discussing on (b) predetermined rates of Recital context, and Section 1.3 Anthem Market Fee Schedule, Section 1.4 Benefit plans, Section 1.5 Billed Charges and Section 1.14 Medically Necessary or Medical Necessity of Section 1; The duties of Hospital on Section 2 discusses about Section 2.4 Credentialing of Hospital Providers, Section 2.6.2 Confidentiality, and Section 2.10.3 Utilization Management We want to demonstrate our integrity to the works of the physicians and allied-health professionals and their area of expertise with integrity and work of ethics. Once we synthesize the problems in parts of the contract, we shall objectively to be optimal and that includes all aspects of delivery of care services at hand, as we have discussed previously in the final stage of the agreement process.
Finally, we will discuss the discrepancies that may arise in the UM process and how we can appeal the part of the UM process in order to satisfy with the content of the UM process.
Hospital Service Agreement
According to the contract, on the part of Recitals context, where the (b) predetermined rates and section 1.3 to 1.5, which focus on the contexts of fees, benefits and billing. Of these, concerns to the physicians, hospitals, and other health care practitioners providing the delivery of such health care services. This also explains that in general that we handle the rates based on the merit system according to the physician’s performance-fee-for-pay merit system through the Planning-programming-budget system followed by the Physician Payment Review Commission and Prospective Payment Assessment Commission on health care delivery service fees. In which, it ensures that a provider(s) is paid accordingly and in compliance with insurance programs as stated in the Section 1.8 Coinsurance; Section 1.9 Coordination of Benefits; Section 1.10 Copayment; and Section 2.10.3., Utilization Management. This provision in part explains about the financial compensation through the state payment system for inpatient-outpatient services, children services, and allied-health professional providers joined by Medicare and Medicaid health insurance program. Other private entitlements are compensated through participants’ employer-fee based payment system. A developing performance framework involving the risks of physicians’ providing care, as it is called, ‘The risk pool’, of costs exceeding performance usually around at 20%, a predetermined fraction of the payment is withheld and deposited in a trust account. It can include institutional costs, putting the physician at risk for services that are ordered. The pool can include a large number of physicians or a smaller set with presumably more similar practices. In oppose to the Capitation, a non-fee compensation strategy, which refers to the accountability of primary care, or a set of referrals for referral specialists on a fixed payment (White, K, et .al, 2006).
In addition to the section 1.14 Medically Necessary or Medical Necessity, this section appear to be vague, unclear with the context that is concerning to a patient receiving diagnosis, treatment and care. To be considerate for the benefit of physician’s liability ensuring that the medication administered or prescribed is legitimate. A separate guideline for Medical Necessary because it shows that the policy is not standardized for those patients who is simply want to receive care when in doubt. Therefore, this potential problem may lead to the conflict of ethics against accrediting bodies’ standards and in whole or in part of legal entitlement. Whereas, the context of Medical Necessity provide a standardized medical care directed by the Orlberg and Anthems and other parties involved. As stated in the last part of the section 1.14: No service is a Covered Service unless it is Medically Necessary. A measurement on the services rendered is based on the severity of a patient needed for such treatment shall be defined as it is necessary to describe the most common diagnosis, treatment, and care requested by patients. Thereby, the process of medical necessity matches the insurance program guidelines.
Under the section 2.4 Credentialing of Hospital Providers, this agreement is upon on the Centers and Medicare and Medicare Guidelines and the licensing or certification requirements by the state. For this contract, this is to strengthen the objectives reflecting the stakeholders’ mission and vision. In general, additional guidelines that is necessary for the health of the hospital and insurance business to operate efficiently. An additional training, education, and post-doctoral training accredited by the Physician Board Certification requirements along with American Internal Medicine Board and other allied-health discipline boards.
In the combinations of practitioner-scholar field of medical background may increase stakeholders’ confident and trustworthy. We want to add the valuation to the integrity of the providers providing care at Orlberg Memorial Hospital as a stated facility that only serves to the acute and chronic illness patients. The goal of expanding prospects and stakeholders to participate the program is by providing a variety of benefits that benefit the community as a whole. Hence, this section 2.4 plays important role of the contract.
A key concern to the Records section 2.6.2 Confidentiality, which depletes the responsibility of Medical Records Administration and the responsibility of participants sharing medical records and supporting records. Under the federal health policy— Health Information Patient Probability Act; Privacy rule; disclosure health medical information; and the confidentiality of informed consent established for the insurance programs that can diverge the group of medical records and informed consents permitting Orlberg to provide medical care and release information to certain persons as permitted by law.
However, these provisions did not strengthen the regulations of biomedical research, for example, particularly on the human subjects participating in the research project, and the distribution of human subjects (i.e., Human Induced Pluripotent Stem Cells). The Investigating Review Board (IRBs) is asked to create an ethic design on the subject of pluripotent stem cells since for the past five years. No Code of Ethics for IPSCs have established as of yet. As such, a transparency in reverse medicine is a new biotechnology method—A positive design that is visible biomedical techniques for physicians to practice ethically. Thus, we strongly recommend that an informed consent convert into multiple informed consents. In the multiple informed consents, would state the knowledge of treatment received; and knowledge of medical records re-use for the research purposes; and knowledge of bodily donors transferred to different area of study or a facility, and so forth.
An external potential problem with the satisfaction of UM process may be the permission to proceed with capital investment by the government, if the parties desire to participate in a specific managed-care monetary program. An internal potential problem with the satisfaction of UM process may be the certification of need (CON) for new services, construction or renovation. This means that the administration costs would necessary to increase the costs to offset the unfixed variables. An appeal to the new services proposal may be related to the associated costs, physician’s fee for pay, and external resources obtained. This should bring the attention to the governance board and discuss the appealing process within 30 days of the complaint. The final decision within 30 days is not highly recommended because of the forecasting financial outlook may look bleak if not analyze the fixed resources against unfixed resources.
Griffin, J.R. & White, K.R (2006) The Well-Managed Healthcare Organization, 6th ed. Health Administration Press, Chicago, Ill