Week 1 discussion
Dq1
Managed Care and Current Trends
In your own words, define managed care and discuss how
managed care will impact healthcare delivery under healthcare reform
Dq2
Quality and Access
In your own words, explain the importance of why managed
care plans must provide quality healthcare.
Week 2 discussion
Dq1
Health Maintenance Organizations
In your own words, explain closed and open panel health
maintenance organizations and the continuum of managed care.
Dq2
Governance of Managed Care Organizations
In your own words, describe the makeup and function of the
board of directors in managed care plans
Week 3 discussion
Dq1
Provider Networks
In your own words, explain contracting approaches for
physicians and hospitals under managed care plans.
Dq2
Federal Regulations
In your own words, discuss the federal regulations and acts
to regulate health maintenance organization plans.
Week 4 discussion
Dq1
Provider Payment
Discuss the challenges and benefits of pay for performance
under managed care plans.
Dq2
Claims and Benefits
Describe the current challenges of claims capabilities,
including ICD-10-CM.
Week 5 discussion
Dq1
Legal Issues
Discuss the clauses and provisions that should be included
in provider contracts
Dq2
Fraud and Abuse
What steps should be taken to mitigate exposure and
liability when the federal government shows up to audit a healthcare
organization?
Week 6 discussion
Dq1
Utilization Review
Describe the three categories of utilization review and
explain why utilization review is the framework for utilization management.
Dq2
Medicare Advantage Plans and Medicaid Plans
Compare and contrast Medicare Advantage plans and Medicaid
plans.
Week 7 discussion
Dq1
State Regulations of Managed Care Plans
Outline the insurance market rules and rating factors and
how HIPAA impacts the rating factors.
Dq2
Federal Regulations of Managed Care Plans (graded)
Discuss the federal agencies that are responsible for the
oversight of HMOs, and discuss when federal regulations or state regulations
would apply to situations, such as HIPAA privacy standards
Week 2 you decide
What’s this?
Scenario/Summary
You are the chief executive officer of Southside HMO, which
serves 495,000 members throughout the eastern region of the United States. It
has come to your attention that several members or patients who participate in
your plan have filed a complaint that your HMO plan does not provide quality
healthcare delivery. Several patients have been denied healthcare services to
see specialists to whom they were referred by their primary care providers.
Your Role/Assignment
The board of directors has asked that you provide a 750-word
report detailing your strategies and recommendations to investigate the
complaints and to identify strategies to ensure that quality management
initiatives are in place to make sure that quality healthcare services are
provided to all members. The strategies and recommendations should be as
specific as possible and include the resources needed for implementation. Your
primary text and journal and website research must be used as a reference to
support your analysis.
Key Players
Review the points of view of the following people to obtain
further insights on this assignment.
Dr. Waters Primary Care
I have been providing healthcare to patients at Sunnyside
Hospital for 5 years, and the hospital recently started contracting in network
with Southside HMO. Southside is denying referrals to specialists for medical
treatment.
Play00:00Mute
Mrs. Brown Patient Advocacy Group Representative Sunnyside
Hospital
I represent patients at Sunnyside Hospital, and more than 30
patients have informed me that Southside HMO is not complying with primary care
provider referrals to see a specialist.
Play00:00Mute
Mr. Robins Mr. Robins CEO Southside HMO
I have been the CEO of Southside HMO for 10 years, and I
ensure that our organization is in compliance with all quality management
initiatives.
Play00:00Mute
Category Points % Description
Content 10 20 Content
is excellent, completely consistent, and appropriate for audience and purpose;
content contains excellent internal integrity; detail is rich and specific.
Organization 10
20 Organization is excellent;
ideas are clear and arranged logically and the transitions are smooth; there are
no flaws in logic.
Design and Format 10
20 Document format is excellent,
with strong visual impact, design, and format.
Style and Readability 10
20 Readability is excellent, with
strong attention to audience, appropriate tone and style, and good transitional
language; there is good use of figurative language.
Grammar and
References 10 20 Grammar,
referencing, punctuation, mechanics, and usage are correct and idiomatic,
consistent with Standard American English; content demonstrates competent use
of mechanics.
Total 50 A
quality paper will meet or exceed all of the above requirements
Week 3 written assignment
Use the DeVry-Keller Online Library to find a research
article (no older than 2009) related to the Patient Protection and Affordability
Act. Discuss physician practice behaviors related to managed healthcare and the
future of managed care under healthcare reform.
Your written paper should be 750 words, double-spaced, and
in APA style. Your primary text and the journal or website research article
must be used as references to support your analysis paper. Use at least three
references.
Please review the Grading Rubric for all written weekly
assignments in the Syllabus, and post your finished paper as a Word document in
the assignment Dropbox,, located at the top of this page, that corresponds with
this assignment and week.
Submit your assignment to the Dropbox, located at the top of
this page. For instructions on how to use the Dropbox, read these step-by-step
instructions.
See the Syllabus section “Due Dates for Assignments
& Exams” for due date information.
Week 4 midterm
A)
Briefly discuss the history of health
maintenance organizations (HMOs) and provide examples of HMOs.
B)
Explain the role of physicians and hospitals in
HMO plans.
C)
Discuss the provisions of the Patient Protection
and Affordable Care Act (PPACA).
D)
Define pay-for-performance (P4P), and explain
how P4P is used to improve the quality of healthcare delivery.
E)
Discuss claims capability and the four core
competencies
Week 5 written assignment
Go to the website CMS.gov at the following web address.
http://www.cms.gov/site-search/search-results.html?q=pay%20for%20performance
Click on one of the articles, and analyze pay for
performance quality and incentives in hospitals, nursing homes, or provider
offices and describe the performance standards and scoring methods.
Your written paper should be 750 words, double-spaced, and
in APA style. Your primary text and the journal or website research article
must be used as references to support your analysis paper. You must use at
least three professional references.
Please review the Grading Rubric for all written weekly
assignments in the Syllabus, and post your finished paper as a Word document in
the assignment Dropbox,, located at the top of this page, that corresponds with
this assignment and week.
Submit your assignment to the Dropbox, located at the top of
this page. For instructions on how to use the Dropbox, read these step-by-step
instructions.
See the Syllabus section “Due Dates for Assignments
& Exams” for due date information.
Week 6 you decide
What’s this?
Scenario/Summary
You are the chief executive officer of Regional Hospital,
which serves a community of 875,000 people throughout the Charlotte Mecklenburg
area of North Carolina. In order to improve health outcomes and reduce costs,
you are reviewing proposals to contract with a disease management company.
Several disease management companies have submitted their proposals to you for
review.
Your Role/Assignment
The board of directors has asked that you provide a 750-word
report detailing your strategies and recommendations to contract with a disease
management company in order to reduce utilization costs and to improve patient
health outcomes. Your report should outline the specific interventions and
model that will be used by Regional Hospital. Your presentation should also
explain cost projections and savings over a 10-year period. The strategies and
recommendations should be as specific as possible and include the resources
needed for implementation. Your primary text and journal and website research
must be used as references to support your analysis.
Key Players
Review the points of view of the following people to obtain
further insights on this assignment.
Mr. Smith CEO, Eastern Disease Management
I have been providing disease management services to
hospitals for 20 years and offer a full line of services, including mailing and
calling both patients and physicians.
Play00:00Mute
Ms. Abbott Disease Management Specialist at Regional
Hospital
I have been working with the disease management department
at Regional Hospital for 5 years, and utilization has continued to increase
although the nurses in the department work directly with the patients.
Play00:00Mute
Ms. Jones Health Education Specialist at Eastern Disease
Management
I have been a health education specialist for chronic
diseases with Eastern Disease Management for the past 2 years and work with
patients and physicians to promote interventions and communication.
Play00:00Mute
Category Points % Description
Content 10 20 Content
is excellent, completely consistent, and appropriate for audience and purpose;
content contains excellent internal integrity; detail is rich and specific.
Organization 10 20 Organization
is excellent; ideas are clear and arranged logically and the transitions are
smooth; there are no flaws in logic.
Design and Format 10 20 Document
format is excellent with strong visual impact, design, and format.
Style and Readability 10 20 Readability
is excellent with strong attention to audience, appropriate tone and style, and
good transitional language; there is good use of figurative language.
Grammar and References 10 20 Grammar,
referencing, punctuation, mechanics, and usage are correct and idiomatic; paper
is consistent with Standard American English; paper demonstrates competent use
of mechanics.
Total 50 100 A
quality paper will meet or exceed all of the above requirements.
Week 7 course project
Your Course Project is due this week. As a reminder, the
length of the final paper should be approximately 8–10 pages, and it should be
double-spaced in MS Word. For full details and a grading rubric, please see the
Course Project content item under Course Home.
Submit your assignment to the Dropbox, located at the top of
this page. For instructions on how to use the Dropbox, read these step-by-step
instructions.
See the Syllabus section “Due Dates for Assignments
& Exams” for due date information.
