EHC 3303 Managed Care

Lecture: Essentials of Managed Healthcare

Outcomes

• Recognize the structure and flow of the course
• Define relevant managed care terms
• Trace the evolution of managed care 

Lecture: History and Types of MCOs

Outcomes

• Explain some differences between common types of managed care organizations  
• Discuss the history of managed care
• Identify some of the issues related to the acceptance of managed care

Lecture: Provider Networks

Outcomes

• Identify issues associated with establishing and maintaining managed care networks
• Define the roles of various types of providers in managed care
• Compare and contrast inpatient and outpatient services and how they relate to contracting

Lecture: Provider Payments and Contracting

• Categorize different payment methods pertaining to MCO and provider types
• Appraise the basic strengths and weaknesses of each payment methodology
• Outline basic approaches to pay for performance programs
• Recognize the challenges in administering such programs
• Delineate common requirements in MCO contracts 

Lecture: Medical Management Utilization, Part 1

Outcomes

• Explore utilization management
• Illustrate core components and concepts of utilization management
• Distinguish the details of disease management
• Compare and contrast acute and chronic care

Lecture: Medical Management Utilization, Part 2

Outcomes

• Appraise the use of provider profiling
• Outline prescription drug benefits under managed care
• Explore managed care challenges associated with behavioral healthcare

Lecture: Medical Management – Quality 

Outcomes

• Appraise the emphasis on prevention and wellness
• Define healthcare quality
• Consider quality measurement principles
• Describe quality improvement approaches
• Model a quality culture
• Identify key external QA organizations 

Lecture: Operational Issues for MCOs

Outcomes

• Examine different mechanisms used by MCOs to market and sell plans
• Discuss differences in operations based on market segments
• Recognize the importance of enrollment and billing in MCO operations
• Describe differences in enrollment and billing across market segments
• Discuss the importance and challenges of the claims and benefit administration process within MCOs
• Compare and contrast reactive and proactive member services
• Explore how MCOs can improve member services

Lecture: Financial Viability of MCOs

Outcomes

• Explain the difference between fraud and abuse
• Recognize the effect fraud and abuse have on healthcare and MCOs
• Describe the relationship between managed care finance and information
• Diagram key information technologies
• Justify the pressure to use IT in MCOs 

Lecture: MCOs in Unique Markets

Outcomes

• Describe the Medicare and Medicaid programs
• Explain the traditional financing of each program
• Evaluate the effect managed care has had on each program
• Define other government sponsored healthcare programs, including TRICARE
• Discuss reasons for differences in the effect managed care has had on each
• Interpret how managed care has or might develop in the global marketplace 

Lecture: Future of Managed Care

Outcomes

• Outline future issues in managed care
• Explore issues and possible approaches to resolving them
• Recognize roles and responsibilities of healthcare executives
• Discuss different state and federal regulations that affect MCOs

Lecture: Affordable Care Act of 2010

Outcomes

• Appraise the implications of the ACA MCOs