Question 1
Situational Case Study: Strategies for Dealing with Health Care Reform 5-6 pages
The CEO of North Eastern Hospital (NEH), Jim James, had been playing the waiting game, assuming that he had plenty of time to prepare for how his institution would be impacted by the Affordable Care Act (ACA). When the Supreme Court upheld the constitutionality of President Obama's signature legislation in June 2012, Jim realized he and his staff needed to quickly rethink the hospital's position and shift strategies. While they had initially seen the health care reform provisions of the ACA as burdensome, now he wanted the staff to think about the opportunities that it offered and how it could enhance NEH and help it to fulfill its mission in serving the community.
The more Jim read and thought about the provisions of the new law, the more convinced he became of the benefits. Since a primary goal of the ACA was to bring the uninsured into coverage, large numbers of uninsured into the community would soon have access to care. And, with insurance companies being required to provide coverage for those with pre-existing conditions, those patients would also have access.
There were many negative stereotypes associated with both groups. While some of these people were indeed very ill, it was also clear that the fact that people didn't have insurance did not necessarily mean they were sick. In reality, many were healthy individuals who, for whatever reason, were uninsured. Some were seasonal workers in organizations that didn't provide coverage to their employees, others opted not to buy coverage, and there were those who just could not afford it and would now be subsidized. Additionally, some with pre-existing conditions had in the past been denied insurance coverage on the basis of relatively minor problems, such as sinusitis, a prior knee injury, removal of a small benign tumor, and so on.
This looked to Jim like a bonanza. Jim wanted to find ways to connect these groups to his hospital, as well as its associated outpatient clinics and excellent pool of physicians and other health care professionals. This led him to thinking about new programs, modifying existing programs, developing marketing strategies, finding ways to capitalize on the pent-up demand for services in the short run, and becoming the provider of choice in the long run.
Discussion Questions:
- What should NEH do? Would you recommend developing new programs? Or, should existing programs be expanded to meet the increased demand? Provide the rationale for what you propose?
- Are there areas of the hospital where demand might be reduced? For example, many of the uninsured may have used the ER as their point of access to care in the past. What would you propose to change this behavior and to address issues relating to the ER?
- What marketing strategies might be developed to attract this new clientele?
- Have there been more recent changes to the ACA on which you would recommend the hospital focus? Be specific?
- Have other changes taken place in your state with regard to other groups of patients, such as those enrolled in Medicaid and the Children's Health Insurance Program (CHIP)? How can NEH respond to meet the needs of these groups?
Question 2
Paper:
Select a quality topic in healthcare from the list below. Prepare a summary document using the table format below. The table should be single spaced and no more than 4-6 pages in length (11 to 12 point font). Except in the case of titles, use complete sentences, i.e., write using narrative format. Include a cover page and a list of references (this is separate from the summary pages).
WRITE ON MEDICAL ERRORS
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HGMT420 Quality Topic Research Summary
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Student Name
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Type your name here.
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Quality Topic
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Provide the name of the quality topic chosen.
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Quality Topic Description
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Provide a detailed description and origins of the quality topic chosen. Indicate in detail who is affected (and how) by this topic (healthcare providers, patients, healthcare organizations, etc.).
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Legislation
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Research legislation and/or policies related to the quality topic chosen. Provide a detailed description of the policies/legislation. Describe the scope of the legislation and how it impacts the organization, providers, and patients.
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Regulatory
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Research Regulatory Agencies that implement policies and enforce legislation related to the quality topic chosen. Discuss in detail at least three (6).
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Conclusion
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Indicate any upcoming changes, regulations, etc. that will impact the quality topic chosen. What does the future hold for this issue? How should healthcare leaders manage this issue in their organizations?
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Question 3
In 5-6 pages, list Nine different types of ambulatory care settings and describe what they do, why ambulatory care makes sense in today's healthcare environment, and compare and contrast free-standing versus hospital-based settings.
Question 4
Assume you are a Maryland resident and Medicaid recipient looking to enroll in a managed care plan, review the Maryland Managed Care Website at: https://mmcp.dhmh.maryland.gov/healthchoice/SitePages/Home.aspx.
Assess and evaluate HealthChoice, Maryland's statewide mandatory managed care program based on the following evaluation criteria.
Using the table format below, answer the questions (using a narrative format) in each section that appear in bold type:
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Assignment #5
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Student Name:
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Type your name here
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Assignment #5 Title
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HealthChoice/Maryland Managed Care Plan
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Benefits Offered and Services Covered
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You want a plan that offers a comprehensive benefits package including preventive care as well as treatment programs for chronic disease management. Also, you may need emergency care and/or care away from home. What questions would you ask to determine the benefits and covered services offered? Evaluate the HealthChoice plan and summarize your findings.
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Cost vs. Benefits
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Managed care plans vary widely in the cost of services offered. It may be tempting to base your selection primarily on the periodic, out-of-pocket costs to you. You can't be sure that the least expensive plan will give you all the medical services you need. Review cost vs. benefits for the HealthChoice plan carefully and summarize your findings.
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Services of the Primary Care Physician
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Choosing your primary care physician (PCP) may be the most important decision you make when enrolling in a managed care plan. The following questions are important when choosing your plan: Please answer each question.
- Can you choose more than one PCP for your family?
- Is there a large choice of primary care doctors and specialists?
- How long is the average wait to get an appointment with the chosen PCP?
- Can you see the same doctor consistently?
- When and how can you change doctors if you are dissatisfied
How does HealthChoice measure up?
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Prescription Drug Benefits
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When evaluating a health plan it is very important to know what kind of prescription drug benefits the plan offers. Depending upon the plan, there are several systems that have been implemented in efforts to control costs. Some plans offer a "generic only" plan. What prescription drug benefits does HealthChoice offer? Are they beneficial to your current drug regimen?
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Provider Network and Geographic Service Area
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Be sure you inquire from the Provider Membership Directory which providers are included in the network and where they are located in your community. If you live in one community and work in another; determine if routine care can be received in either location. Does HealthChoice have a strong network of Providers in a geographic area that is amenable to you? Must you go to different locations for different services? If you have a child away at school, does the network extend to that area?
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Commitment to Quality of Care and Service
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What measures of quality care and satisfaction of service are available? It is worthwhile to find out if the plan has been accredited by the National Committee for Quality Assurance (NCQA). NCQA is the most common accrediting body for network plans. Review and report on what measures of quality care and satisfaction are available for HealthChoice.
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Customer Satisfaction
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How do enrolled members feel about the plan? There are various objective forms of measurement used to determine "quality services" given by managed care plans such as accreditation, HMO report cards and/or publications produced by the industry. You would be wise to look at any that measure customer satisfaction. The National Committee for Quality Assurance (NCQA) mission is to provide information that enables purchasers and consumers of managed health care to compare plans based on quality. Their web site may be reached at http://www.ncqa.org/
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Limitations, Maximums, or Exclusions
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Lifetime Cap refers to the maximum dollar amount of benefits available to a consumer in a managed care plan during his or her lifetime. This amount becomes important when confronted with a life-threatening disease or accident that requires prolonged care involving expensive therapeutic intervention and support. Does HealthChoice outline limitations, maximums, or exclusions?
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