Textbook for Reference:
Getzen.,E.,Thomas. (2013). Health Economics and Financing. 5th Edition.
1. RMF: Look at the current public and private options available for care. Are these working? What works well? What does not? Are there any options you would like to see as the universal health care of the future? If so, why? If not, what should be changed? Please ensure to substantiate your response with a personal account of your own experience in the work place/ others. Explain in 150- 200 words
2. Chap 4: Who pays for losses: insurance companies or the people who buy insurance? What is an “actuarially fair” premium? Do insurance companies take risks, or do they just put a price on risks? Who takes care of people when they need medical care they cannot afford? Are people who think they will become sick more likely to obtain insurance? Substantiate your response with a personal account of your own experience in the work place/ others. Explain in 150- 200 words
3. Chap 7: Why are there more foreign doctors practicing in the United States than U.S. doctors practicing overseas if the needs are much greater there? Can medical groups advertise to attract more patients and increase market power? Are bigger practices more efficient? Is price discrimination legal? Why are some patients charged more for the same service? Why and how are doctors giving discounts on fees? Explain in 150- 200 words.
4. Do you feel managed care plans are the solution to the health care crisis in the United States? Support your response. Your response should be 200-300 words. Please ensure to substantiate your response with scholarly sources or a personal account of your own experience in the work place.
5. Based on the answer below do you feel managed care plans are the solution to the health care crisis in the United States? Your opinions only! 150 word count!
Answer 4: I like the flexibility of the PPO (Preferred Provider Organization Plan). It is a little on the expensive side but the network of doctors associated with this plan is vast. There are no strict requirements for seeing specialists and there is no need to formally change your primary care doctor with the plan if you decide to see someone else. Health Maintenance Organization (HMO) plans are relatively cheap but they have strict requirements that needs to be followed such as obtaining referrals from your primary care doctor to see specialists and co-pays associated with each visit. I had an HMO plan once and was appalled when I received a bill from the emergency room physician stating my insurance denied the claim for untimely filing and that I was responsible for paying him. I contacted the payer thinking there was some kind of mistake but was told I was indeed responsible and it stated so in my contract. The bottom line is that in order to receive quality care and less expense on the consumer’s end, you have to invest in paying for the right coverage.
6. Based on the answer below do you feel managed care plans are the solution to the health care crisis in the United States? Your opinions only! 150 word count!
Answer 5: Managed care plans are a type of health insurance. They have contracts with health care providers and medical facilities to provide care for members at reduced costs. These providers make up the plan’s network. How much of your care the plan will pay for depends on the network’s rules. Managed Care is a health care delivery system organized to manage cost, utilization, and quality. Medicaid managed care provides for the delivery of Medicaid health benefits and additional services through contracted arrangements between state Medicaid agencies and managed care organizations (MCOs) that accept a set per member per month (capitation) payment for these services. You have you HMO’s, PPO’s and your POS’s flexible plans. Your Health Maintenance Organization usually only pay for care within the network. You choose a primary care doctor who coordinates most of your care. Preferred Provider Organization usually pay more if you get care within the network. They still pay part of the cost if you go outside the network and your Point of Service plans let you choose between an HMO or a PPO each time you need care. So yes I do feel like the plans may not be the full solution to the health care crisis, but I feel like it will help because you are only getting what you need.
7. What would be the risks and benefits of a young, healthy person choosing a managed care plan? What would be the risks and benefits of an older person with a chronic disease selecting a managed care plan? Your response should be 200-300 words. Please ensure to substantiate your response with scholarly sources or a personal account of your own experience in the work place.
8. Based on the answer below, what would be the risks and benefits of a young, healthy person choosing a managed care plan? What would be the risks and benefits of an older person with a chronic disease selecting a managed care plan? 150 words!
Answer 7: Managed care plans typically cover a wide range of health services such as preventive care and immunizations for adults and children, general checkups, diagnosis and treatment of illness (including necessary tests, doctors’ visit, prescription medications, and hospital care), and complete prenatal (pregnancy) and newborn care.” Additionally, most managed care plans offer some services for the diagnosis and treatment of mental health conditions and substance abuse problems. I think that the risk of a young, healthy person choosing a managed care plan is that they wouldn’t really use the plan as much due to certain health services it covers, and the fact that they really wouldn’t have to visit the doctor as much because they are considered healthy. However, a young person low use of medical care allows them to build up HRA balances with their employer. A young and healthy person can benefit financially by selecting low-cost, less comprehensive plans, which can reduce premium costs by up to 50 percent. The risk to an older person choosing a managed care plan is that they will have a higher premium rate than a younger, healthier individual. These older individuals who have pre-conditioned chronic illnesses will have to see different types of doctors and specialists in order to get the treatment they need. However, the managed care plan they have chosen will basically cover all of their medical needs with little or no out-of-pocket fee to them.
9. Based on the answer below, what would be the risks and benefits of a young, healthy person choosing a managed care plan? What would be the risks and benefits of an older person with a chronic disease selecting a managed care plan? 150 words
Answer 8: With any insurance, there are risks and benefits that coming along with it. Although there is more risk to older individuals with chronic conditions, young, healthy individuals face a few risks as well, depending on the managed care plan that they have obtained. A HMO is the strictest of all managed care plans. Under the HMO umbrella, individuals that have a HMO pick one primary physician that handles every aspect of the patient’s care. If the individual needs to see a specialist, the primary doctor has to give a referral before the patient can see another physician. If the individual goes outside of the network, the individual will pay all costs. The benefit of young, healthy individuals with a HMO is that they are less likely to need to see other physicians and seek out a referral. If there is a situation that comes up, the young individual does not have to be in a rush to see another physician. There is little risk for young, healthy patients unless they are wanting to see a physician outside of the network. For older individuals with chronic conditions, there are more risks than there are benefits when using a HMO. Older individuals are restricted from seeing anyone other than primary and when referrals are needed for specialists, the primary has to approve them. An individual with chronic conditions may need several specialist and this can be problematic because of the need for a referral. The network may not even have all the specialist needed for someone with a chronic condition and that individual may have to seek a physician outside of network. This a big risk for the individual because they will pay for all services. I do not see any benefits for older individuals where it concerns a HMO.
A PPO is more flexible and there are many benefits to both young and older individuals. PPO’s do not require a primary physician or referrals. This is beneficial to both young and old individuals because it gives each more freedom. Older individuals with chronic conditions can make appointments with different specialists when needed instead of requesting a referral. The same applies for young individuals. There is also the benefit to both young and old because staying inside the network provides full coverage and only copayments. The only risk to both young and old when it comes to a PPO is that if either go outside of the network, there will be higher cost and possibly, there will not be coverage for some services. It is not as much of a risk for young individuals but for older individuals because if they do need to go outside of the network for specialist that are not under the PPO umbrella, there is the chance of not being able to afford services.
Point of Service (POS) is a managed care plan that combines PPO and HMO services. It benefits young and older individuals because of the lower costs. There are low risks to young individuals because like HMO, it establishes a primary. The primary physician once again refers patients to other specialists but because the young individual is in healthy condition, there is low risk of needing a specialist. The risk that would occur with a young, health individual is the need for approval for emergency situations that might require hospitalization, surgery or an x-ray. Older individuals are once again at risk with these managed care plan. This leaves older individuals with chronic conditions needing to seek referrals for specialists. According to Getzen (2013), “A written referral signed by the PCP must be obtained before seeing a specialist, getting an x-ray, or being admitted to the hospital.” (p.111) Furthermore, Getzen (2013) states that “Before ordering surgery, the plan might require precertification that an operation was necessary, and perhaps it might also require a second opinion from another doctor before approving the procedure.” (p.111) Patients are then limited to the choice of drugs they receive.
In all, young, healthy individuals have very low risks when dealing with managed care plans. They enjoy more benefits because in most cases, there is no need for specialists and they enjoy lower costs for care. On the other hand, older individuals face many risks when dealing with managed care plans. Many older individuals need several specialists and two out of three require referrals. The other does not require a referral but the individual may have to look outside of the network if there is not a specialist available. There are very few benefits other than lower costs.
Reference: Getzen., E., Thomas. (2013). Health Economics and Financing. 5th Edition. Retrieved from https://newclassroom3.phoenix.edu/Classroom/
10. Review and Discuss Competition and the Cost of Medicare’s Prescription Drug Program: 150 word count. https://www.cbo.gov/publication/45552 \
11. Review and discuss the Obesity Trends Among U.S. Adults Between 1985 and 2010 presentation. 150 word count. http://www.cdc.gov/obesity/data/prevalence-maps.html
12. The Health Care Reform Project I. Each part builds upon the last portion completed.
Select a current health care economic issue, such as the influence of illegal immigrants on health care economics in the United States.
Write a 175-350 words summary describing the issue.
Perform a literature search on the issue. Find at least three articles and summarize each article in 175-350 words. Format your response consistent with APA guidelines.
The Health Care Reform Project II. Resources: Results from Health Care Reform Project, Part I
Research three possible solutions to your selected health care economic issue, as determined in part 1. The solutions do not need to be extensive, but must represent solutions identified in your research.
Describe your findings and proposed solutions in 700- 1,050 words from the information and articles collected in the Health Care Reform Project, Part I assignment.
Format your paper consistent with APA guidelines.
The Health Care Reform Project III. Resource: Health Care Reform Projects, Parts I and II
Prepare a Microsoft® PowerPoint® presentation in which you summarize health care reform material.
Assume you are making a presentation to the board of directors concerning your investigation into the economic issue you submitted for your Health Care Reform Project assignments in Weeks Two and Three.
Have a minimum of 10 to 15 slides with extensive speaker notes, augmenting and expanding on the information presented in each slide.
Include the following in your presentation:
• Describe the economic issue selected.
• Identify methods and tools common to addressing economic challenges in the health care industry.
• Discuss how the methods and tools identified relate to health care reform.
• Determine the most effective method(s) and tool(s) that could be used to resolve the economic issue selected.
• Identify various payment sources and mechanism used in the health care industry.
• Determine which payment source(s) and mechanism(s) are the most effective to resolve the economic issue selected.
• List the steps needed to implement your solution.