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Canyon College

COURSE SYLLABUS: Understanding Managed Care

Course Title: Department: Instructor:

HS440 - Understanding Managed Care Health Sciences Carmen Herbel-Spears, MSN, BSN, RN, CHCA, COS-A E-Mail Vita

OVERVIEW

Textbook: Online Bookstore

Managed Care: What It Is and How It Works, Second Edition, by
Peter Kongstvedt, MD, FACP. Jones and Bartlett Publishers, 2003/2004.
ISBN: 076372498X ISBN13: 9780763724986

Was known as:

Kongstvedt, Peter. (2002), Managed care: What it is and how it works,
Aspen Publishers, ISBN: 083422089X

Internet resources will be listed in the lecture material and used to supplement readings.

Description:
This course is designed to introduce the student to managed care as it exists in various forms in the United States today. The course includes a discussion of managed care structures, products, methods of reimbursement, and contracting for enrollees, network providers, and/or services. The role of the healthcare administrator and the responsibilities of those under administrative span of control in a managed care environment is presented and illustrated through exercises and discussion.

OBJECTIVES & COURSE TOPICS
Objectives:
1. Identify the driving forces of managed care
2. Describe structures used in the delivery and funding of managed care
3. Classify the products offered by managed care organizations
4. Compare methods of reimbursement under managed care
5. Contrast the role of the government as purchaser and regulator of managed care
6. Describe the role of quality improvement within managed care
7. Differentiate methods of utilization management common to managed care organizations
8. Discuss the role of physician credentialing
9. Analyze the practice of accrediting managed care organizations
10. Analyze negligence and evaluate its impact on managed care service delivery
11. Describe how breach of contract and breach of warranty can be used as causes of action against managed care organizations
12. Identify current trends and issues that are having an impact on managed care

Course Topics:
1. Driving forces of managed care
2. Managed care structures and products
3. Methods of reimbursement in managed care
4. Managed care contracts
5. The role of government as regulator and purchaser
6. Quality Improvement in managed care
7. Utilization Management in managed care
8. Marketing and other internal operations
9. Medical Staff Credentialing
10. Accreditation
11. Legal issues related to managed care
      * Negligence
      * Breach of contract
      * Breach of warranty
12. Trends & Issues

Overview

Outline

GRADING
Grading:
The grade you receive in this course reflects your performance in the following areas;

Exercises
Exercises for this course are designed to enhance lecture and reading assignments they are to be completed within one week of assignment and posted for grading. The response to the exercise should be 200-250 words in length and well thought out. Each exercise is worth 10 points for a total of 80 possible points; 25% of grade

Mid-Term Exam
Will be posted at the end of the fourth session and must be completed within 72 hours of posting: 100 points possible; 25 % of grade

Final Exam
Will be posted at the end of the eighth session and must be completed within 72 hours of posting 100 points possible; 25% of grade

Discussion Questions
A discussion question(s) will be listed at the end of each lecture. The student is expected to complete a 100 - 150 word answer and post within a week. The answer should be concise and well thought out to earn the maximum number of points; 80 points possible; 25% of grade

Total 360 points A = 330 - 360 points B = 287 - 329 points C = 250 - 286 points D = 213 - 249 points F = 212 points or less

Student Responsibilities & Instructor Availability
Student Responsibilities:
1. Review lecture weekly
2. Complete text and other readings as assigned
3. Complete and post learning activities
4. Complete and post answers to discussion questions
5. Complete exams as assigned

Instructor Availability:
The instructor may be contacted at any time through the e-mail address above and will respond usually within 24 hours.

Outline

Session1

Session2

Session3

Session4

Session5

Session6

Session7

Session8

Session 1: Driving forces of managed care

Lecture Objectives
* Identify four forces that are driving changes in healthcare today
* Describe the impact of each of these forces on healthcare

Reading: Chapter 1

Exercise:
Select one of the driving forces and research it on the Internet. From this discuss how this driving force may change over the next 5 years.


Session 2: Managed care structures and products

Lecture Objectives
* Differentiate and describe managed care products
* Differentiate and describe managed care structures

Reading: Chapter 2

Exercise:
Review your own personal healthcare coverage. Describe the structure and/or product and evaluate its effectiveness in meeting your own healthcare needs. What elements of managed care does it have?


Session 3: Methods of reimbursement in managed care and managed care contracts

Lecture Objectives
* Evaluate the different types of managed care reimbursement systems
* Discuss the impact of managed care contracts on healthcare organizations

Reading: Chapter 3

Exercise:
Identify how capitation has impacted your healthcare organization. If you do not currently work in a healthcare organization, interview someone who does and describe how capitation has impacted their organization.


Session 4: The role of government as purchaser and regulator

Lecture Objectives
* Analyze the role of the government as payer and purchaser of healthcare services

Reading: Chapter 6

Exercise:
Do you think there is a conflict of interest between the government as a purchaser and regulator? Explain your rationale.


Session 5: Quality Management & Utilization Management in managed care

Lecture Objectives
* Describe methods used by managed care organizations to ensure quality of care
* Analyze utilization management methods used by managed care organizations

Reading: Chapter 4

Exercise:
As a consumer of healthcare services, what quality issues are important to you and why?


Session 6: Medical staff credentialing and accreditation

Lecture Objectives
* Discuss the credentialing process used by managed care organizations
* Identify the primary purpose of credentialing
* Explain the primary purpose of accreditation

Reading: Chapter 7

Exercise:
How would you deal with a physician who was upset over the use of utilization information as part of the recredentialing process?


Session 7: Legal issues related to managed care & internal operations of the managed care organization

Lecture Objectives
* Analyze breach of contract as an area of potential legal liability for managed care organizations
* Analyze breach of warranty as an area of potential legal liability for managed care organizations
* Discuss negligence and managed care organizations

Reading: Supplementary Reading!! (Instructor will provide)

Exercise:
Do you think managed care organizations like HMO's should be liable for negligence of contracted providers? Explain your position.

How should Managed Care Organizations control costs without affecting patient care

Session 8: Trends & Issues

Lecture Objectives
* Evaluate the impact the trends discussed in the lecture on the healthcare industry

Reading: Epilog

Exercise:
As more and more HMO's leave the marketplace because of low profits, what will happen in these markets?