One way in which a MCO can control cost, quality, and access is through various structured compensation and reimbursement plans. The two most common examples are fee for service and capitation. Moreover, there are different types of reimbursement systems for inpatient and outpatient services. Answer the following questions in regard to the above information:

Examine the three types of inpatient or outpatient reimbursement systems?

Evaluate the key advantages and disadvantages of each system from the point of view of a managed care plan and the hospital?

What is the difference between capitation and FFS? Evaluate the type of market appropriate for each reimbursement method. Support your answer by providing an example of an MCO using either of these methods.

What do you understand by the term “UCR”? With what form of reimbursement is this term associated? Search current information from the Internet and evaluate the use of UCR in the managed care industry.

Reimbursement procedures are complex and detailed, especially those associated with government programs such as Medicare. Part of the regulatory requirements of Medicare is to prevent illegal billing practices such as churning, upcoding, and unbundling. You can search these topics (http://oig.hhs.gov) . You can also search on federal regulations for reimbursement procedures and fraud and compliance guidelines and education materials.

Based on your research, respond to the following questions:

Review the latest enforcement actions on this website. Identify a case where at least one of the following illegal actions was used””churning, upcoding, and unbundling.

What are some of the specific examples of actions taken against providers engaged in these practices?

After answering the above questions, read the following information:

P4P is a type of compensation method for providers based on evidence-based practices that promote better quality outcomes. Find at least two online sources of information, such as professional associations and government resources, from the South University Online library or the Internet on P4P compensation programs: one in favor of and one against this type of compensation program for providers.

Now, using the readings this week and the information gathered from the above sources:

Explain, in your own words, the negative consequences of P4P program.

Describe the market forces making this type of compensation program popular.

Managed care has had a profound impact on the way that health care is delivered and paid for in the United States. A large portion of Healing Hands Hospital’s revenue comes from managed care reimbursement making managed care a very important part of the business process. Part of the Task Force’s work will include obtaining feedback from the community and a public relations committee has been formed to help educate the community when decisions are made about changes to Healing Hands Hospital. Mr. Johnson, Healing Hands Chief Financial Officer, has asked you to help provide some training to the members of the public relations committee to help them understand managed care and other possible models for reimbursement including value-based reimbursement and Accountable Care Organizations (ACOs), so this can be included in their campaign of community education. Your report to Mr. Johnson should include:

Identify three types of managed care plans, such as Preferred Provider Organizations (PPO) and how they impact the way that health care is delivered at Healing Hands Hospital.
Managed care has changed dramatically in the United States over the years. What did managed care look like 10 years ago compared to how it looks today?
Discuss the future of managed care as a viable reimbursement model for Healing Hands Hospital compared to Accountable Care Organization model and valued based reimbursement.
Reimbursement by CMS for Medicare patients is also an important source of revenue for Healing Hands Hospital. Include a description of the different models for Accountable Care Organizations (ACOs) and what would be a good strategy for Healing Hands to ensure the highest level of Medicare reimbursement for the future.
Through legislation such as the Affordable Care Act and MACRA, there are regulations and requirements that are designed to improve patient quality of care and ensure highest levels of reimbursement. Include how these laws impact Healing Hands Hospital and its financial plans.
Mr. Johnson, like all healthcare management professionals, believes that the data and information presented must be backed by good research and the reference sources must be listed appropriately in the written report.

Be sure to include at least three references for the information presented in your report using APA formatting.

Scenario
Throughout this course, you will provide information and analysis using a fictitious community hospital, Healing Hands, located in a suburban community about 15 miles outside of a major metropolitan area. Each week, you will complete specific assignments, and in the final weeks of this course, you will provide a final report detailing your findings.

The following scenario will be utilized throughout this course to assist you in completing each week’s assignment:

Healing Hands Hospital is an acute care community hospital in a suburb 15 miles outside of a large metropolitan city. The hospital, which was founded over 50 years ago, is dedicated to serving the local community consisting of working professionals, families and retired individuals. It has 320 beds and is comprised of a group of 500 physicians. The hospital has in-patient services for short-stay acute care patients; an in-patient mental health unit; an ambulatory surgical clinic; and specialized units in cancer, maternal and child services, orthopedics, and cardiac care. Healing Hands Hospital serves a community of approximately 500,000.

Mr. Jeff Magone, the new Chief Executive Officer of Healing Hands Hospital recognizes that an important trend in healthcare delivery that is linked to reimbursement is accountable care and integrated delivery models. He has set the goal for the hospital to remain financially viable and increase services and quality of care available to the community served by Healing Hands Hospital. To accomplish this goal, Mr. Magone realizes that there are several options to consider such as:
Addition of outpatient services including urgent care centers and affiliations with more local physician practices,
Merging with another community hospital in a neighboring suburb, or
Affiliating with one of the two large academic medical centers in the city.
Mr. Magone and the hospital Board of Directors have discussed the options and they realize that some changes need to be made to not only maintain and improve the high quality of patient care for which Healing Hands is recognized but also to ensure future financial stability in the changing healthcare industry.

Mr. Magone and the Healing Hands Hospital Board of Directors have created a “Future of Healing Hands” Task Force, and as a Director of Operations, you have been asked to participate on the Task Force and provide support through research, analysis and reports to the Task Force as they evaluate options to meet the goals outlined by Mr. Magone. You will work with your supervisor, the Chief Operating Officer, Ms. Woods, as well as the Chief Financial Officer, Mr. Johnson, and provide research and analysis. Community leaders will also be part of the Task Force providing recommendations and input from the community served by Healing Hands Hospital. Mr. Magone realizes that developing outpatient services, urgent care clinics, affiliations with medical practices or merging with an academic medical center will also require upgrades to the electronic health record system (EHRs) and other computer systems. Therefore you will also work with the hospital’s Chief Information Officer to determine if current systems such as the EHRs and Clinical Decision Support Systems are scalable or need to be replaced.

Mr. Magone has made it clear that patient needs and future financial stability are driving the project. He wants to ensure that Healing Hands Hospital stays current with reimbursement and quality care models and remains financially sound through reimbursement by Medicare and other health insurance plans. Leadership at Healing Hands also recognizes that strong relations with the community and the Healing Hands staff will be imperative to success.

Throughout this course, you will research and analyze different aspects of the developing strategic plan for this initiative. Each week, you will build the information needed for the plan, and in the final weeks of this course, you will provide a final report detailing your findings.