Wait a second!
More handpicked essays just for you.
More handpicked essays just for you.
Clinical integration in physician-hospital relationships
Don’t take our word for it - see why 10 million students trust us with their essay needs.
CONTRACTUAL ARRANGEMENTS: This alignment option involves a series of contracts or agreements between the physician and physician group with the hospital or health systems which involves wide range of agreements like on-call arrangements, physician recruitment, medical directorship and stipends, clinical co-management services, customer service programs, professional service arrangements, legal partnerships and joint ventures with predetermined payment methods. When compared with physician employment, this alignment model exhibits low degree of integration and the agreement between the both parties stipulates the list of functioning services and method of compensations and incentive payments using pre-determined incentive metrics and quality …show more content…
outcomes. Each contract arrangement varies from one another in terms of level of integration, compensation methodology and provision of clinical and managerial services. On-call arrangements between the hospitals and physician group ensure the adequate physician coverage in various emergency department and inpatient services which involves per diem on-call pay strategy and activation payment methods. Medical directorship enables to hospitals or physician practices to use the expertise of physicians who have excelled in their department and service provisions and use their skill in allowing to adapt through effective programs and link to achieving positive outcomes. Legal partnerships between the two parties allows to share risk and at the same time either party can use other party’s skill in developing successful strategy in performing specific healthcare services for example ambulatory care. Professional service arrangements is the emerging trend in current healthcare market to sustain the market share by increasing the volume is either an integration model where it is owned by a hospital or health system and operates a physician clinic by contracting with independent physician group to render professional services. In delivering services to hospital-owned clinic by physician group, the compensation or payments are contractually dependent on the professional services rendered with involving multiple approaches in determining the payments such as base salaries, per diem payments, and production models. Most preferred professional service arrangements are related to provision of services through radiology, pathology and anesthesiology departments. These professional service arrangements are beneficial for both physician and hospitals as reason for the financial and operating performance in response to market imperative under new healthcare reform process in integrating the quality and efficiency improvements with hospitals enabling to leverage their infrastructure, payor contract and provider based status while physicians have a facility to receive fair market value compensation. SERVIVE-LINE CLINICAL CO-MANAGEMENT: Co-management is a legal agreement between a hospital and practicing physicians who can work together in medical groups by recognizing the participation rewards of working together by their efforts to developing, managing and improving the quality and efficiency under an enterprise with both the parties being independent. Co-management is the quick and proven strategy for implementing hospital- physician collaboration with agreement based on the predetermined fee to the clinical and/ or management services offered by the physician or physician group to the hospital for a period of time. Under this arrangement, the service level agreement between the both parties define the specific quality requirement, operating and financial goals. Co-management arrangement provides the hospital in developing a new program or care model in the community either through contracting for clinical or management services, managing entire service line such as cardiology, orthopedics, imaging center, cancer therapy, etc. or contracting for ambulatory services. Usually, the price determination is tied to work effort or predetermined baseline prices, but in times of at risk under nonperformance it is related with equity return rates. Since, this arrangement possess such risks of regulatory scrutiny to both parties, the whole arrangement requires to be legal and regulatory compliant which requires expert counsel for both hospitals and physicians. JOINT VENTURES: These are a part of contractual agreement where a hospital or healthcare organization will approach for agreement with the physician group or independent practicing physicians to have an advantage of shared benefits under the contracting agreements to work under a single enterprise. These joint ventures may range from leasing arrangements, purchased services arrangements and contracting outpatient services. These agreements enables to have equity in terms of capital investments, responsibilities and sharing risks and revenues by entering into a financial partnership between the both parties. Joint ventures are often entirely regulated under legal considerations and the venture can be a limited liability corporation or partnership involving either a single project i.e. functioning for single service line or for operating different levels of services. Due to the legal considerations, the agreement terms should exhibit compliance between the both parties and several federal as well as state laws comes in the operating function like Stark law and anti-kickback laws. Typically involved service lines under these joint venture agreements are ambulatory surgery centers, outpatient services, imaging and endoscopy facilities and urgent care facilities. Considering the reduced reimbursements by Medicare Ambulatory surgical centers are suffered and shown to hinder contracts under the new healthcare regulations. PHYSICIAN-HOSPITAL ORGANIZATION: (PHO) Physician- Hospital Organization is formed by hospital and physicians or physicians group for obtaining as well as negotiating contracts with the insurance plans and employers.
Through this organization hospitals and small group practices can be provided with better reimbursements, efficient claim management and better delivery of care by negotiating with the payors and obtaining better health plan contracts. PHOs serve a messenger role between the providers and payors by submitting the fee schedules to the network physicians and enabling efforts to have contracting terms between the providers and payors. Traditionally, the contracts were between the hospitals and payors or small group practices and payors with PHOs as a third party or messenger, but with the emerging trend of clinical integration between the physicians and hospitals PHO enables both the parties involved in the contact agreement which provides better bargaining leverage in negotiation as the collaboration will lead to controlling hospital costs and improving the quality. With the current Medicare and Medicaid payment models involving bundled payments, global payments and episode based payments along with clinical integration between the physicians and hospitals, this Physician – hospital organization arrangement reduces the adversarial or confrontational risk involved by making contracts less complex and reducing the costs by greater cohesion and cooperation between the both parties compared to traditional PHO independent contractual agreements with the insurance companies and payors. Most important concern with the PHO service model is the potential of antitrust liability in the establishing fee schedule and contracting as price fixing arrangements in between the competitors is considered offensive and with the clinical integration between the physicians and hospitals can resolve such issue. Under these arrangements, ownership and governance of the PHO is given emphasis enabling that both the
hospital and physician group has equal responsibility that provides physicians to have power in influencing the contracting decision processes that affect the medical practices.
To guarantee that its members receive appropriate, high level quality care in a cost-effective manner, each managed care organization (MCO) tailors its networks according to the characteristics of the providers, consumers, and competitors in a specific market. Other considerations for creating the network are the managed care organization's own goals for quality, accessibility, cost savings, and member satisfaction. Strategic planning for networks is a continuing process. In addition to an initial evaluation of its markets and goals, the managed care organization must periodically reevaluate its target markets and objectives. After reviewing the markets, then the organization must modify its network strategies accordingly to remain competitive in the rapidly changing healthcare industry. Coventry Health Care, Inc and its affiliated companies recognize the importance of developing and managing an adequate network of qualified providers to serve the need of customers and enrolled members (Coventry Health Care Intranet, Creasy and Spath, http://cvtynet/ ). "A central goal of managed care is containing the costs of delivering care, but the wide variety of organizations typically lumped together under the umbrella of managed care pursue this goal using combination of numerous strategies that vary from market to market and from organization to organization" (Baker , 2000, p.2).
Integrated Managed Care Organization- The organization is properly aligned for the primary driver being cost cutting services. Since all entities within the organization are responsible and affected by any expenses endured on any entity being unfavorable or favorable, the foundation serves as a primary motivator to reduce costs at all levels. This alignment eliminates any financial gains from driving high utilization of services or higher intensity services within the organization. Ultimately, this system allows the physician medical group to drive patient care, being responsible for the clinical care decisions as opposed to health plan making those decisions as designed in other organizations. This is the preferable model for Medicaid
This group is more focused on satisfaction, access and quality of care. Providers, or practitioners, are also key stakeholders within an organization. The term provider can encompasses not only physicians and surgeons, but also nurses, physical and occupational therapists, technicians, and other members of a clinical staff. Providers fall into two categories, primary, which includes hospitals and health departments and secondary, which includes educational institutions and pharmaceutical companies. Providers are focused on the best treatments for patients and are involved in delivering health services and products. The final element of the MCQ model is the employer who by far is the largest paying and purchasing stakeholder of an organization. The employers focus is primarily on their return on investment within an organization. Cost and quality is a focus for employers when choosing health benefits but are mindful that access is just as important. Within the Patient Healthcare model, MCQ explains the interactions between the four elements of employer, patient, provider and payer while the Iron Triangle focuses on the factors of cost, quality, and access. The Patient Healthcare model charges healthcare leaders with the task of balancing satisfaction with the stakeholder (employer, patient, provider, and payer) in relation to cost, quality and access. This may be very difficult since stakeholders may have competing priorities. Changes and variations made in how healthcare organizations operate may have profound effects on how stakeholders perceive the quality, access and cost. For instance, a patient may consider cost to be a top priority when seeking healthcare and at the same time the healthcare organization may consider raising costs and therefore devaluing access and quality. Patients who begin to incur high out-of-pocket costs may begin to perceive a financial
The cost of Medical equipment plays a significant role in the delivery of health care. The clinical engineering at Victoria Hospital is an important branch of the hospital team management that are working to strategies ways to improve quality of service and lower cost repairs of equipments. The team members from Biomedical and maintenance engineering’s roles are to ensure utilization of quality equipments such as endoscope and minimize length of repair time. All these issues are a major influence in the hospital’s project cost. For example, Victory hospital, which is located in Canada, is in the process of evaluating different options to decrease cost of its endoscope repair. This equipment is use in the endoscopy department for gastroenterological and surgical procedures. In 1993, 2,500 cases where approximately performed and extensive maintenance of the equipment where needed before and after each of those cases. Despite the appropriate care of the scope, repair requirement where still needed. The total cost of repair that year was $60,000 and the repair services where done by an original equipment manufacturers in Ontario.
In recent times, healthcare organization across the nation are facing unprecedented challenges as they strive to improve the overall quality of care provided to their patient’s population, while improving their organization’s financial performance. Furthermore, uncertainty of new reimbursement models, diminishing reimbursement, and complicated compliance regulations are playing the role of a catalyst for streamlining the Chargemaster process in majority of healthcare organizations.
In Medicare's traditional fee-for-service payment system, doctors and hospitals generally are paid for each test and procedure. This drives up costs by rewarding providers for doing more, even when it’s not needed. ACOs continue to utilize fee for service by creating incentives to be more efficient by offering bonuses when providers keep ...
Healthcare payers agree with the idea of Evidence-Based Medicine (EBM) to advocate for pay-for-performance in provider reimbursement on quality and efficiency. The fundamental system that most payers use to compensate physicians and provider associations embodies enticements for excellence and efficiency. Reimbursement can be affected by the P4P approach and other factors such as the claims process, out-of-network payments, legislation, audits and denials. While the same P4P approaches are attempts to commence incentives and new strategies into the healthcare, the underlying arrangement of the compensation system produces many per...
When one examines managed health care and the hospitals that provide the care, a degree of variation is found in the treatment and care of their patients. This variation can be between hospitals or even between physicians within a health care network. For managed care companies the variation may be beneficial. This may provide them with opportunities to save money when it comes to paying for their policy holder’s care, however this large variation may also be detrimental to the insurance company. This would fall into the category of management of utilization, if hospitals and managed care organizations can control treatment utilization, they can control premium costs for both themselves and their customers (Rodwin 1996). If health care organizations can implement prevention as a way to warrant good health with their consumers, insurance companies can also illuminate unnecessary health care. These are just a few examples of how the health care industry can help benefit their patients, but that does not mean every issue involving physician over utilization or quality of care is erased because there is a management mechanism set in place.
A merger is a partial or total combination of two separate business firms and forming of a new one. There are predominantly two kinds of mergers: partial and complete. Partial merger usually involves the combination of joint ventures and inter-corporate stock purchases. Complete mergers are results in blending of identities and the creation of a single succeeding firm. (Hicks, 2012, p 491). Mergers in the healthcare sector, particularly horizontal hospital mergers wherein two or more hospitals merge into a single corporation, are increasing both in frequency and importance. (Gaughan, 2002). This paper is an attempt to study the impact of the merger of two competing healthcare organization and will also attempt to propose appropriate clinical and managerial interventions.
Health Maintenance Organizations, or HMO’s, are a very important part of the American health care system. Also referred to as managed care programs, HMO's are combinations of doctors and insurance companies that are formed into one organization. This organization provides treatment to its members at fixed costs and decides on what treatment, if any, will be given based on the patient's or doctor's current health plan. Sometimes, no treatment is given at all. HMO's main concerns are to control costs and supposedly provide the best possible treatment to their patients. But it seems to the naked eye that instead their main goal is to get more people enrolled so that they can maintain or raise current premiums paid by consumers using their service. For HMO's, profit comes first- not patients' lives.
Managed care dominates health care in the United States. It is any health care delivery system that combines the functions of health insurance and the actual delivery of care, where costs and utilization of services are controlled by methods such as gatekeeping, case management, and utilization review. Different types of managed care plans came into development by three major factors. These factors include choice of providers, different ways of arranging the delivery of services, and payment and risk sharing. Types of managed care organizations include Health Maintenance Organizations (HMOs) which consist of five common models that differ according to how the HMO is related to the participating physicians, Preferred Provider Organizations (PPOs), Exclusive Provider Organizations (EPO), and Point of Service Plans (POS). `The information management system in a managed care organization is determined by the structure of the organization' (Peden,1998, p.90). The goal of a managed care system is to provide subscribers and dependants with needed health care services at the lowest possible cost. Certain managed care plans also focus on prevention by trying to keep members healthy.
retrospect to its governing authority (Shi & Singh, 2012). However, private and public agencies are the controlling constituent in today’s business. Free markets allow patients to choose providers without the prior approval of insurance companies. The current system offers a proposed plan of limited physicians in exchange for payment of services. Because the potential has been given to the payers, they regulate the cost of services rendered through contractual
One being the Health Maintenance Organizations (HMO), which was first proposed in the 1960s by Dr. Paul Elwood in the "Health Maintenance Strategy”. The HMO concept was created to decrease increasing health care costs and was set in law as the Health Maintenance Organization Act of 1973, after promotion from the Nixon Administration. HMO would, in exchange for a fee, allow members access to employed physicians and facilities. In return, the HMO received market access and could earn federal development funds. An HMO is a integrated delivery system that combines both the delivery and financial aspects of health care for consumers. Under the HMO, each patient is appointed to a primary care physician (PCP), who is essentially accountable for the long-term care of the members that she/he has been assigned and any specialists that a patient needs to see should be referred by their PCP. Some examples of HMOs are Kaiser Permanente and Humana. HMOs are licensed at the state level, under a license that is known as a certificate of authority. A pro of an HMO is that treatment for a patient can begin prior to their insurance being authorized; A member may benefit from this because there would be little to no treatment delays. A con of an HMO is that in order to save cost, most HMOs provide narrow provider networks; A member may not benefit if in an emergency because their “in-network” emergency room might be far or there are “quick-care” in their
The purpose of this paper is to examine the Heritage Valley Medical Center case study. The paper will start off with a brief background of Heritage Valley, along with a summary of the major problems and issues faced there. Next, the author will explain the role that was chosen while addressing the challenges of Heritage Valley and their reasoning in doing so. The author will then identify the strengths and weaknesses of Heritage Valley and offer to select the best alternative and recommended solutions, which will be followed by a brief description of the evaluation plan that could be used to measure the effectiveness of the recommended solution.
In particular, ProCare’s role was central to the outputs and the process of the BSP, such as enhanced communication between key actors and promoted the BSP to citizens. As stated previously, PHOs need to establish a stronger position on their services direction, for example, a network of providers or purchasers of primary health care services. If the former, a network as a form of coordination mechanism, then PHOs, in theory, have the capacity to work closely with DHBs to deliver primary health care that is in line with the PHO services agreement. However, if the latter role is desired, a market as a form of coordination mechanism, thus an examination of PHOs role and governance arrangement will be required to ensure PHO have the capacity and capability to achieve policy objectives (Cordery, 2008; NZ Doctor, 2015; HomeCare Medical,