HCA 413 / HSA 613-Fundamentals of Managed Care

HCA 413 / HSA 613-Fundamentals of Managed Care

Introduces the history, philosophy, business principles, and current structure of the managed care industry. Reviews key concepts related to the various payment methodologies including capitation, discount fee-for-service, and case rates. Explores the functions of case management, utilization review and budgeting. Also examines issues related to regulatory requirements and national health policy

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COURSE OBJECTIVES:

Define managed care and various managed care models including health maintenance organizations, preferred provider organizations, exclusive provider organizations, independent physician association models, managed health plans and managed indemnity insurance plans and self-funded plans.
Describe the history and philosophy of the managed care industry.
Explain the role of managed care in controlling health care costs.
Describe the legal and regulatory environment of managed care.
Compare attitudes about managed care from the perspectives of the consumer, provider purchaser and payer
Explain the primary characteristics of managed care products/plans including organizational structure, benefits, pricing, and reimbursement.
Contrast the roles and functions of utilization review, quality management and quality control in managed care.
Outline the information and information system needs of a managed care plan.
Define the primary elements of a managed care contract.
Analyze market information, outcomes data, and utilization trends to negotiate a managed care contract.
Identify the ethical concerns related to managed care and provider contracting.

MATERIALS OF INSTRUCTION:

Required Text:

Managed Care: What it is and How it Works 3rd Edition; Peter R. Kongstvedt; Aspen; 2009. ISBN 9780763759117.

Supplemental Materials:

To be provided by the instructor.

GRADING CRITERIA:

Each successful student is expected to:

Actively contribute to all class discussion questions and reflections regarding assigned readings.
Maintain a journal of discussion questions and reflections regarding assigned readings.
Prepare and present to the class a critique of current articles dealing with relevant aspects of managed care.
Prepare a position paper for presentation to the class. Clearly define and defend your position on a particular area of aspect of managed care.
Complete all reading and preparatory assignments prior to the start of each workshop.
Demonstrate knowledge of the subject(s) via written test.
Demonstrate good attendance and active participation.