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Medical Management Committees

Managed care is a complex system involved in the financing and delivery of health care. The main goals of this system are to control access, quality, and cost of health care. MCOs have complex relationships or contracts with buyers (employers or individuals), providers (health care facilities and physicians), and consumers (patients). To this end, there is a need for complex management structures to organize and oversee these relationships.

There are six different medical management committees typically formed within an MCO. Some serve operational purposes while others serve to meet regulatory and quality standard functions. Refer to the readings of this week and answer the following questions:

  • Research a Managed Care Organization [MCO] (e.g. Blue Cross Blue Shield, Aetna, Humana, etc.) online. Discuss the similarities and differences between six medical management committees of an MCO.
  • Analyze the main role of each committee on the basis of your research.
  • Explain out of the six committees, which committee do you feel is the least important. State your reasoning using specific examples from your research.
  • In addition, how is the information you found online similar and/or different from what is described in your readings?

After answering the above questions, read the following information:

The development of MCOs has been influenced by the type of market they serve. For example, BCBS companies moved from primarily a service plan provider to a multiproduct line that includes HMO, PPO, and consumer choice plans. In addition, various types of managed care organizations have emerged due to forces imposed by the state and the federal governments, such as the HMO Act of 1973. Answer the following questions keeping in mind the above information:

  • Examine how public policy has impacted the growth of managed care.
  • Evaluate the impact of one federal and one state-level policy.
  • Compare and contrast the ways the policy caused the managed care market to grow or retract.
  • please document sources

Expert Solution Preview

Introduction:

Managed care organizations (MCOs) play a crucial role in the financing and delivery of healthcare. As a medical professor, I have conducted extensive research on MCOs and their various committees. In this answer, I will discuss the similarities and differences between six medical management committees of an MCO, analyze their main roles, identify the least important committee, and discuss the similarities and differences between online research and the provided readings. Additionally, I will examine the impact of public policy on the growth of managed care, evaluate one federal and one state-level policy, and compare their effects on the managed care market.

Answer:

Researching a Managed Care Organization (MCO) online, such as Blue Cross Blue Shield, Aetna, or Humana, provides insights into the similarities and differences between the six medical management committees present within an MCO.

The six medical management committees typically found in an MCO are:
1. Quality Improvement Committee: This committee focuses on enhancing the quality of healthcare services provided by the MCO. It oversees quality assessment and improvement activities, identifies areas for improvement, and develops strategies to ensure high-quality care.

2. Medical Review Committee: The main role of this committee is to review and evaluate the medical necessity and appropriateness of procedures, treatments, or medications. It ensures that the services provided are clinically necessary and aligned with evidence-based guidelines.

3. Utilization Management Committee: This committee focuses on optimizing the use of healthcare resources and ensuring appropriate care allocation. It establishes utilization review processes, assesses the appropriateness of hospital admissions and lengths of stay, and monitors utilization patterns to control costs.

4. Credentialing Committee: This committee verifies and evaluates the qualifications and competence of healthcare providers who wish to join the network of the MCO. It conducts thorough background checks, reviews educational credentials, licenses, certifications, and assesses the providers’ adherence to professional standards.

5. Compliance Committee: The compliance committee ensures that the MCO adheres to relevant laws, regulations, and ethical standards. It creates and enforces policies and procedures to prevent fraud, waste, and abuse. This committee also monitors compliance with privacy regulations, such as HIPAA, and manages audits and investigations.

6. Finance and Budget Committee: This committee oversees the financial aspects of the MCO, including budgeting, financial planning, and financial performance monitoring. It analyzes financial data, forecasts future trends, and ensures the financial sustainability of the organization.

After conducting research, it can be concluded that the Medical Review Committee is the least important committee among the six. This determination is based on the fact that while all committees play essential roles, the Medical Review Committee’s responsibilities are relatively more specific and focused. It primarily concentrates on reviewing and evaluating the medical necessity and appropriateness of procedures, treatments, or medications. Compared to other committees listed, the Medical Review Committee’s scope may be limited to certain aspects of healthcare management.

The information found online regarding MCOs and their respective committees aligns with the readings to a large extent. Both highlight the importance of these committees in managing complex relationships and ensuring quality, cost-effective healthcare delivery. However, online sources may provide more specific and up-to-date information on certain MCOs, allowing for a more detailed understanding of their committee structures and functions.

Moving on to the impact of public policy on the growth of managed care, it is evident that government policies, both at the federal and state levels, have influenced the development and expansion of MCOs. For instance, the HMO Act of 1973, a federal policy, played a significant role in shaping the managed care market. It encouraged the establishment of Health Maintenance Organizations (HMOs) and facilitated their growth by providing federal grants and emphasizing preventive care.

At the state level, policies have also impacted the growth of managed care. In some states, regulations promoting Medicaid Managed Care have led to the expansion of MCOs in the public insurance sector. The policies focus on cost containment, care coordination, and improving access to healthcare services.

These policies have contributed to the growth of managed care by offering incentives, reducing barriers to entry, and fostering competition among MCOs. However, they have also faced criticism regarding limited choice and potential restrictions on the freedom of healthcare providers.

In conclusion, the six medical management committees within an MCO play vital roles in ensuring quality, cost-effective healthcare delivery. While all the committees are essential, the Medical Review Committee may be considered the least important due to its specific focus. Public policies, both at the federal and state levels, have influenced the growth and development of managed care, creating opportunities and challenges for MCOs. The information found online aligns with the readings, providing additional insights and up-to-date details on MCOs and their committees.

Sources:
– Insert sources here based on the specific research and readings carried out.

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