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    Managed Care Organizations

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    You are a new physician setting up your own practice in a new town. You are researching the different MCOs offered in your area and are considering becoming a physician for one of these networks. You have also invited the sales representatives of several health plans to speak with you about the benefits of choosing their plans.

    Based on the above scenario, answer the following questions:

    What effects would joining a MCO have on your clinic regarding staffing, patient volume, and financial stability?
    What policies and procedures should be used by the MCOs to reduce costs for their clientele?
    Discuss the ethical issues or concerns about MCOs providing a lower quality of care compared to traditional fee-for-service (FFS) organizations?
    What are some of the questions you would ask each representative about his or her company's specific plan that will help you make a decision?
    Do you believe that the evolution of MCOs and consumer driven health plans (CDHPs) has affected the healthcare environment today by integrating the financing and delivery of healthcare services? If yes, how?
    How have the roles and relationships between physicians and patients changed by each of these types of plans?

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    Solution Preview

    Managed Care Organizations

    By definition, A Managed care Organization refers to an organization that delivers healthcare through a system that enhances efficiency and reduces cost by combining the functions of health insurance, delivery of care and administration. Each patient is allocated a set amount of payment per month.
    On the other hand, A Fee for Service (FFS) or Medicaid refers to an insurance system where a physician provides care and is reimbursed for the amount of service provided.

    1. What effects would joining a MCO have on Staffing, Patient Volume, and Financial Stability?

    1.1. More staff required because of workload implications from many programme patients and processing payment documents as MCOs cover a variety of services such as preventive, immunizations, general check-ups , diagnosis and treatment
    1.2. High patient volumes because of group programme patients who may be referred to your clinic from other doctors or as new members join the MCO
    1.3. There is a possible financial guarantee and eventual stability from the volume of patients who join the MCO

    2. What Policies and procedures should be used by the MCO for reducing costs for clientele?

    2.1. Prioritize preventive strategies such as immunizations.
    2.2. Scheduled physician contacts tend to prevent patients from falling ...

    Solution Summary

    Joining Managed Care Organizations by physicians may have implications on their staff, patient volumes and financial stability.
    MCOs may develop policies and proceedures to control costs and this cost control may present ethical issues. It is possible to study and determine the effect of MCOs and consumer driven health plans which have integrated financing and healthcare delivery on today's healthcare environment.
    MCOs and fee-for service plans may have changed roles and responsibilities between patients in different ways.