Choice #2 - Summit Oaks Hospital Summit Oaks Hospital is a privately owned, for-profit hospital located in the affluent community of Summit, New Jersey. It is a 38-bed facility and is not associated with any other healthcare provider. Summit Oaks provides psychiatric as well as chemical dependency inpatient as well as outpatient treatment for both children and adults (Summit Oaks Hospital, 2016). Summit Oaks does not provide any other healthcare services; therefore, any patient requiring medical treatment secondary to psychiatric or chemical dependency issues is transferred to another hospital for treatment. Founded in 1902 the hospital has provided treatment to individuals in the entertainment industry as well as local citizen. …show more content…
Yet, this policy would also allow them to decline services for patients who possess policies that would not sufficiently cover the cost of treatment and/or contain a no balance billing clause. Managed Care Contracts Managed care organizations and Summit Oaks would have established important objectives between what services they consider essential and those services which are desirable (Kongstvedt, 2013). Also as part of the managed care contract, a solid basis for a working relationship would have been established between Summit Oaks and the managed care organization (MCO). The would include CHOICE #2 – SUMMIT OAKS HOSPITAL …show more content…
Furthermore, a MCO many times considers mental health and substance abuse services as a carve-out from the standard surgical and medical aspects of a policy. An understanding of this carve-out between Summit Oaks and the MCO established as the point of contracting with the MCO would be highly beneficial both parties by eliminating policy unknowns. In addition, many MCOs do not use straight charges with hospitals but instead, per diems. Per diems are one fee for each day of hospital service without consideration of adjustments (Kongstvedt, 2013). While successful per diems depend on predicting services, this would be especially beneficial to this psychiatric hospital and it could use service-specific per diems; therefore, not needing to negotiate any outliers which occur. The presence of these elements enables both Summit Oaks and the PPO, EPO, CDHP, IDS or other managed care organization to manage the payment and costs of services. While in the past MCOs could have a reduced lifetime limit for mental health benefits versus other medical services, the Mental Health Parity Act of 1996 requires that the lifetime dollar limit be the same as for other service areas (Hebert, 2009). This also makes contracting with MCOs more desirable than they may have been in the past. Self-Pay
General Practices Affiliates is considering an offer from Titus Lake Hospital to join under a provider leasing model. Under a provider leasing model, Titus Lake Hospital is purchasing General Practices Affiliates’ services. The practice will retain control of personnel, management, and practice policies. Titus Lake Hospital submitted financial reports to assure transparency during the lease agreement process. The following analysis will discuss whether Titus Lake hospital is a viable financial partner for General Practice Affiliates, possible implications of the lease, and recommendations.
In Texas, most Medicaid services and all Children’s Health Insurance Programs (“CHIP”) services are delivered through managed care. The Texas Health and Human Services Commission (“HHSC”) contracts with state-licensed managed care organizations (“MCOs”), and pays them a monthly amount to coordinate health services for Medicaid or CHIP members enrolled in their plans. The MCOs contract
Another downfall to HMO coverage is selective-contracting. This is a process where hospitals deny treatment to patients because their...
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
The first Minnesota insane hospital opened in St. Peter, in 1868. The original name was “The Asylum for the Dangerously Insane”. The hospital housed 50 patients. Rochester opened in 1879, 68 mentally ill patients transferred from St. Peter. Rochester State Hospital closed in 1982. “The number of hospitals and the number of Minnesotans placed in them continued to grow. By 1960, the State of Minnesota operated 11 state hospitals. On any given day, there were approximately 16,000 people who were residents and patients in those hospitals”. http://mn.gov/mnddc/learning/document/GT033.PDF Now, Minnesota has closed 10 out of 11 large state hospitals. Anoka-Metro Regional Treatment Center (AMRTC) is still open operating with 110 beds. There is still
Abelson, Reed. "Lacking Rules, Insurers Balk at Paying for Intensive Psychiatric Care." The New York Times. The New York Times, 28 Sept. 2013. Web. 16 Mar. 2014. .
Mandated fee schedule will work short-term, until physicians find a way to shift the demand curve for personal interest. The shift of the demand curve cuts into patient’s visit, it allows an increase of patients to be seen. This price control method results with mandatory negotiating and regulated fee schedules.
As described in the Health Care in the United States textbook and notes, managed care services are delivered through organizations, better known as MCO (Managed Care Organizations). MCO’s are a category of insurance company – main way health insurance is delivered – that guarantees a member’s health care will be provided. The key functions of insurance, such as funding, distribution/delivery, and payments are taken over and overseen by MCO’s. This means MCO’s control quantity and reimbursement, resulting in cutting costs. One specific way managed care attempts to control costs is by gatekeeping. Gatekeeping is fundamentally a patient needs a referral from his primary physician to see any other specialist inside their network. Making referrals necessary helps cut the cost immensely. For example, a patient cannot make an appointment to see a
In addition to costly outliers, both the IPPS and HH PPS share other similar payment adjustments in order to ensure that all eligible beneficiaries have access to the appropriate services. They include adjusting the payment rate for partial episodes, and low-utilization of services. The outlier adjustment is made in order to pay for beneficiaries whose cost of care exceeds the threshold amount for their assigned group, just as for the IPPS 3. Under the HH PPS, the low-utilization adjustment can be made for beneficiaries whose episodes consist of four or fewer visits. When this is the case, workers will be paid based on the services they provide per visit multiplied by the number of visits provided during the episode 3, 4. One additional payment adjustment made under the HH PPS, the partial episode payment adjustment (PEP) can be made for patients who change HHAs or are discharged and readmitted within a 60-day episode. When this happens, a new episode will begin for that patient and they would now required a new plan of care and assessment. The adjustment to the original 60-day episode proportionately reflects the length of time the patient remained under the agency’s care
This writer decided to develop a lobbying plan for the Mental Health Parity Act (MHPA). The MHPA was passed in 1996 and it was only the beginning of what would change the life of people with mental illness. Essentially, the point of the MHPA is for people with mental illness and substance use disorder to have the same level of care that a person with a medical condition has, without limitations. Initially, the MHPA started out by employers offering as part of a group insurance. That changed in 2014 when President Obama passed the Affordable Care Act (ACA). With both the ACA and MHPA, everyone including individuals outside of a group could take advantage of the same benefits as the groups did. Everyone predicted that the MHPA with ACA would
According to the Centers for Medicare and Medicaid Services (CMS), an ACO is "an organization of health care providers that agrees to be accountable for the quality, cost, and overall care of Medicare beneficiaries who are enrolled in the traditional fee-for-service program who are assigned to it.(CMS, 2015).” ACO’s incorporated Chronic Care Management (CCM) Programs to help better oversee patients with multiple chronic conditions who see multiple specialists and allow for better continuity amongst providers caring for the same patient. ACO’s have yet to incorporate mental health services into your CCM program even though one in four primary care patients suffer from a mental disorder.
DCH contracts with private insurers, referred to as Care Management Organizations (CMOs), to administer healthcare for these and other state employee groups. The DCH establishes and monitors specific criteria for quality of care, access and provider quality delivered by the CMO’s to Georgia’s participants. The current three CMO’s supporting the Georgia Medicaid and PeachCare Kids market are Wellcare, Anthem (Amerigroup) and Centene Corporation; with the potential for others to enter the market as the state negotiates future contracts. These three insurers cover six regions within the state, with a minimum of two insurers in each region and all three CMOs covering the greatest concentration of population in the Atlanta market. In 2015, the DCH supported 1.966 million participants in Medicaid and PeachCare Kids, with a cost to the state of $9 billion (XXXXX Website –gvt
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.
The revolving door phenomenon is commonly used to describe chronically mentally ill patients utilizing inpatient services in a cyclical pattern. This phenomenon suggests that even if these individuals represent a small proportion of the general population, they represent a significant number of psychiatric inpatient hospitalizations, which are costly. Not only do the health care costs affect the patient but also the community and economy, especially those with Medicare or Medicaid. In 2006, The Agency for Healthcare Research and Quality found that 6 out of every 10 hospitalizations for a mental health condition were paid by Medicaid and Medicare (Saba, Levit, & Elixhauser, 2008). Among 15 states, mental health ranked among one of the top five
Managed health care actually combines health care delivery with the financing of services provided. This was intended to replace conventional fee-for service plans with much more affordable quality of care to the health consumers as well as the providers who was in agreement with the restrictions. However, managed care is becoming challenged due to the growth of consumer-directed health plans, which defines employer continuations and asking employees to be more responsible within their health care decisions and cost-sharing. The Americans health care system has been changing the way their health care services are organized and delivered. As seen by the movement from traditional fee-for-service systems to managed care networks. Ranging from structured staff model HMOs to the lesser structured preferred provider organizations (PPO). Statistics show that 60 million Americans are enrolled with some type of managed care program within the response to regulatory initiatives which affect health care cost and quality. Managed care organizations are responsible for the health of their enrollees, which can be administered by a physician’s group, health system, or even a hospital. Much of the managed care financing is through a method called capitation, and the enrollees are assigned to a select primary care provider, which serves as a gatekeeper.