Managed Care

Topic: Managed Care
Order Description
This examination is intended to test your ability to identify, discuss, analyze and understand critical issues in the administration of managed care programs and organizations. Relevant materials to assist you with the examination include the assigned text, lecture notes, and outside reading.

Please answer four (4) of the following six questions. I am looking for evidence of your understanding of the basic issues presented during the class. I do not expect quotes or references as I would a research paper, unless you wish to do so. Your answers are to be no less than two full pages for each question. On your exam, please indicate either the question or the question number.

Answer 4 of 6 (no less than two full pages per question)

1. In the last decade, medical care experts predicted that most Medicare beneficiaries would soon be enrolled in a Medicare Senior Risk Plan (Medicare Advantage). Not only did this not happen but many seniors opted out of HMOs and some HMOs have dropped their Medicare Advantage plans due to lowered reimbursement. Briefly discuss Medicare HMOs, including how the federal government compensates Medicare Advantage for health care services, including the proposed cuts to Medicare Advantage under ACA.
2. Historically, one of the ways HMOs have controlled medical costs is to limit the number of physicians under contract. How does the concept of “Any Willing Provider” compromise this strategy?
3. The federal government offers managed care to veterans in the form of TRICARE, which is composed a several programs. Briefly discuss TRICARE and some of the challenges to TRICARE in the future.
4. From a global perspective, we find elements of managed care in a number of countries. Please identify and discuss one example of another country which appears to be managed care friendly.
5. Briefly discuss the relationship between Current Procedural Terminology (CPT), Relative Value Scales (RVS), Resource Based Relative Value Scales (RBRVS) and Global or Bundled Fees as contained in the ACA.
6. What is the relationship between Stop-Loss and Adverse Selection in managed care?

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