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EHC 3303 Managed Care

Course Description

Analyzes the organizational structure and management of managed healthcare. Emphasizes current trends, including the payment and financial aspects of America's managed healthcare system. 

Course Objectives

After completing this course, students will be able to

  • Provide an introduction and overview of managed care
  • Explain the history and types of managed care organizations
  • Define provider networks, payments, and contracts
  • Describe medical management with a focus on utilization and quality
  • Explore managed care operations
  • Appraise healthcare finance and information management
  • Examine special markets, including Medicare and Medicaid
  • Discuss the Affordable Care Act
  • Predict the future of managed care

Week 1

Lecture: Essentials of Managed Healthcare


  • 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


  • 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

Week 2

Lecture: Provider Networks


  • 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 

Week 3

Lecture: Medical Management Utilization, Part 1


  • 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


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

Week 4

Lecture: Medical Management – Quality 


  • 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 

Week 5

Lecture: Operational Issues for MCOs


  • 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

Week 6

Lecture: Financial Viability of MCOs


  • 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 

Week 7

Lecture: MCOs in Unique Markets


  • 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 

Week 8

Lecture: Future of Managed Care


  • 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


  • Appraise the implications of the ACA MCOs

The course description, objectives and learning outcomes are subject to change without notice based on enhancements made to the course. November 2013