HP 609 Week 4 Discussion 1: Health Care Delivery Systems
Shi (2019) defines Managed Care as “an organized approach to delivering a comprehensive array of health care services to a group of enrolled members through efficient management of services needed by the members and negotiation of prices or payment arrangement with providers”. The two challenges managed care faces are limited choices in health care providers and consumers are left with no option in choosing out of network providers when there is a single managed care organization dominating the area. There are two types of state-legislated statutes to address the two challenges according to Shi (2019),
- Any willing provider laws provide fair entrance to all health care providers to enter the managed care program network as long as qualifications are met.
- Freedom of choice Law allows all enrollees able to seek care out of network providers without facing penalty.
Looking into the state of Massachusetts, senior care option (SCO)is one of the managed care programs funded by both medicare and medicaid. The program is subcontracted to private health insurance companies for management. The purpose of the SCO program is to reduce the cost of medicare and medicaid by case managing within a network of providers. The SCO program was first started by two companies as Evercare and Senior Whole Health back in 2004 in Massachusetts. Till now, there are at least six health plans provided SCO options in the state since the reduction in cost is promising to both medicare and medicaid. The Any Willing Provider law is adopted and implemented in Massachusetts. It applies to the SCO program to ensure competitive advantages. However, each insurance plan will be setting its own requirement and negotiate pricing in service with health care providers through contracting. Smaller health plans are not likely able to be contracted with healthcare Giants as Partner’s, big brand hospitals like Brigham and Women’s and Dana Faber….etc. because according to Dafny et al (2017), the reimbursement rate is fixed per state, the higher cost the less revenues it is. And the fact smaller health plans can only survive when narrowing the provider network. Smaller health plans can not afford the contract with high end health care providers. Freedom of Choice law is not presented within the SCO program. All enrollees within the SCO program can only receive care through network providers. Despite out of network service occasionally granted, there is a lot of restriction and utilization review before authorization. Enrollee risks totally out of pocket payment when care is received thorough out of network providers. In addition, through the study by Haeder et al (2020), it shows enrollees are found to travel a longer distance to network providers which post other challenges to patients who have chronic diseases. Unfortunately, Massachusetts state can only recommend the statute of Freedom of Choice but can not mandate it through the SCO plan. Enrollees may have to exit out of the SCO option in order to choose out of network provider or choosing another SCO plan is accepted by the health care provider.
Since the state continues to monitor and adjust the model of SCO program, the section of free choice by enrollees will be improved in
the future. The within network only providers restriction has caused high enrollee turns over rate as they are picking and choosing when and where to switch insurance in order to get the desired service done without out of pocket pay. In addition, enrollees also face losing their long time primary care physician when a contract is getting in between. As managed care continues to evolve, we shall see the optimal integration in the long run.
Important information for writing discussion questions and participation
Welcome to class
Hello class and welcome to the class and I will be your instructor for this course. This is a -week course and requires a lot of time commitment, organization, and a high level of dedication. Please use the class syllabus to guide you through all the assignments required for the course. I have also attached the classroom policies to this announcement to know your expectations for this course. Please review this document carefully and ask me any questions if you do. You could email me at any time or send me a message via the “message” icon in halo if you need to contact me. I check my email regularly, so you should get a response within 24 hours. If you have not heard from me within 24 hours and need to contact me urgently, please send a follow up text to
I strongly encourage that you do not wait until the very last minute to complete your assignments. Your assignments in weeks 4 and 5 require early planning as you would need to present a teaching plan and interview a community health provider. I advise you look at the requirements for these assignments at the beginning of the course and plan accordingly. I have posted the YouTube link that explains all the class assignments in detail. It is required that you watch this 32-minute video as the assignments from week 3 through 5 require that you follow the instructions to the letter to succeed. Failure to complete these assignments according to instructions might lead to a zero. After watching the video, please schedule a one-on-one with me to discuss your topic for your project by the second week of class. Use this link to schedule a 15-minute session. Please, call me at the time of your appointment on my number. Please note that I will NOT call you.
Please, be advised I do NOT accept any assignments by email. If you are having technical issues with uploading an assignment, contact the technical department and inform me of the issue. If you have any issues that would prevent you from getting your assignments to me by the deadline, please inform me to request a possible extension. Note that working fulltime or overtime is no excuse for late assignments. There is a 5%-point deduction for every day your assignment is late. This only applies to approved extensions. Late assignments will not be accepted.
If you think you would be needing accommodations due to any reasons, please contact the appropriate department to request accommodations.
Plagiarism is highly prohibited. Please ensure you are citing your sources correctly using APA 7th edition. All assignments including discussion posts should be formatted in APA with the appropriate spacing, font, margin, and indents. Any papers not well formatted would be returned back to you, hence, I advise you review APA formatting style. I have attached a sample paper in APA format and will also post sample discussion responses in subsequent announcements.
Your initial discussion post should be a minimum of 200 words and response posts should be a minimum of 150 words. Be advised that I grade based on quality and not necessarily the number of words you post. A minimum of TWO references should be used for your initial post. For your response post, you do not need references as personal experiences would count as response posts. If you however cite anything from the literature for your response post, it is required that you cite your reference. You should include a minimum of THREE references for papers in this course. Please note that references should be no more than 5 years old except recommended as a resource for the class. Furthermore, for each discussion board question, you need ONE initial substantive response and TWO substantive responses to either your classmates or your instructor for a total of THREE responses. There are TWO discussion questions each week, hence, you need a total minimum of SIX discussion posts for each week. I usually post a discussion question each week. You could also respond to these as it would count towards your required SIX discussion posts for the week.
I understand this is a lot of information to cover in 5 weeks, however, the Bible says in Philippians 4:13 that we can do all things through Christ that strengthens us. Even in times like this, we are encouraged by God’s word that we have that ability in us to succeed with His strength. I pray that each and every one of you receives strength for this course and life generally as we navigate through this pandemic that is shaking our world today. Relax and enjoy the course!
Hi Class,
Please read through the following information on writing a Discussion question response and participation posts.
Contact me if you have any questions.
Important information on Writing a Discussion Question
- Your response needs to be a minimum of 150 words (not including your list of references)
- There needs to be at least TWO references with ONE being a peer reviewed professional journal article.
- Include in-text citations in your response
- Do not include quotes—instead summarize and paraphrase the information
- Follow APA-7th edition
- Points will be deducted if the above is not followed
Participation –replies to your classmates or instructor
- A minimum of 6 responses per week, on at least 3 days of the week.
- Each response needs at least ONE reference with citations—best if it is a peer reviewed journal article
- Each response needs to be at least 75 words in length (does not include your list of references)
- Responses need to be substantive by bringing information to the discussion or further enhance the discussion. Responses of “I agree” or “great post” does not count for the word count.
- Follow APA 7th edition
- Points will be deducted if the above is not followed
- Remember to use and follow APA-7th edition for all weekly assignments, discussion questions, and participation points.
- Here are some helpful links
- The is a great resource
Reference
Dafny, L. S., Hendel, I., Marone, V., & Ody, C. (2017). Narrow networks on the health insurance marketplaces: prevalence, pricing, and the cost of network breadth. Health Affairs, 36(9), 1606-1614.
Haeder, S. F., Weimer, D. L., & Mukamel, D. B. (2020). Going the extra mile? How provider network design increases consumer travel distance, particularly for rural consumers. Journal of Health Politics, Policy and Law, 45(6), 1107-1136.
Shi, L., & Singh, D. A. (2019). Delivering health care in America: A systems approach (7th ed.). Jones & Barlett Learning
Value: 100 points
Due: In an effort to facilitate scholarly discourse, create your initial post by Day 4, and reply to at least two of your classmates, on two separate days, by Day 7.
Note: In this type of discussion, you will not see the responses of your classmates until after you have posted your own response to the question below.
Initial Post
Select one topic below to write about in your initial post. Please make it clearly which topic you chose to write about in your initial post. Write 500 to 750 words related to:
- Topic 1: Choose one sector of health care delivery and financing that interests you (medical technology; outpatient and primary care services; inpatient facilities and services; managed care and integrated organizations; or long-term care). What are two challenges facing the sector you have chosen? What are two policies to address those challenges? What are the politics of those policy recommendations, if any? Make clear in your entry if they are policies already adopted; proposed/under consideration; and/or ones that you would recommend.
- Topic 2: Discuss two challenges facing the health professions. What are two policies that would address those challenges? What are the politics of those policy recommendations, if any? You may write about the health professions in general or choose a specific health profession to write about. Make clear in your entry if they are policies already adopted; proposed or under consideration; and/or ones that you would recommend.
Cite additional sources beyond the Learning Materials for this week.
Replies
Reply to at least two of your classmates. In your reply posts, each reply should be on a topic different from the one you chose to write about. Each reply should be 200 to 400 words. You should cite at least one to two sources that add new information in response to your classmate’s post.
Please refer to the for details on how this activity will be graded.
Posting to the Discussion Forum
- Select the appropriate Thread.
- Select Reply.
- Create your post.
- Select Post to Forum.
The policies focused on nurse-to-patient ratios are the minimum mandates (McHugh, 2021). This policy is scarcely implemented and this is the part that needs to change. Here in Hawaii, there are no such mandates and it is up to each individual care facility to staff as they see fit. A study in Queensland Australia looked at the effects of an implemented nurse-patient ratio policy. They found that the cost of adding nursing staff was only half the amount they would save from readmissions and longer length of stays (McHugh, 2021). With fewer nursing staff, there are fewer people to address the concerns of the patients as well as to complete all the tasks required of them. There is another policy that is not yet in effect. It is called the Safe Staffing for Quality Care Act. The act is under review in New Work and would hospitals to staff appropriately for nurses to safely provide care to patients (Lasater, 2021). As someone who has experienced working in a skilled nursing facility, I feel very strongly about having safe nurse-to-patient ratios. When I would work evening shifts I would have 23 patients to myself. Majority of my shift was doing medication passes and the CNA’s were the ones interacting with the patients and telling me what they need. There was hardly any time for assessments or getting to know the patients, let alone chart. In my opinion, if there was at least one more nurse on the floor, the quality of care given would increase immensely.
Another issue that invades long-term care is elder abuse. There is an association specifically for creating policies around elder abuse. The two proposed policies they have are mandated training for elder abuse and age-specific consumer protection. They argue that there is mandated training for child abuse but none exist for the elderly (Elder Abuse, 2019). As someone who currently works in pediatrics, I have never come to this conclusion before and am glad that it has been brought to my attention. As for consumer protection, the organization states that they want to improve consumer experiences for the elderly that are unable to understand materials due to hearing or vision loss (Elder Abuse, 2019). As for this policy, I understand the want for change, but this can apply to the deaf and blind population that are not considered elderly as well. The organization has been able to send a representative, Dr. Mark Lachs, to the White House to testify in front of the US Senate Committee about elder abuse. He has also collaborated with the World Health Organization.
Note: The value of each of the criterion on this rubric represents a point range (example: 25–20 points, 20–15 points, 15–10 points, 10–0 points).
Criteria | Exceeds Expectations | Meets Expectations | Needs Improvement | Inadequate | Total Points |
---|---|---|---|---|---|
Quality of Initial Post | Initial post is on time and of the correct length (500–750 words).
All components of the initial post requirements are addressed. Course content synthesis is applied. References are included according to the Discussion instructions. 25 points |
Initial post is on time and of the correct length (500–750 words).
Most components of the initial post requirements are addressed. Course content synthesis is applied but limited. References are included according to the Discussion instructions. 20 points |
Initial post is one day late.
Does not meet the correct length (500–750 words). Some components of the initial post requirements are addressed. Course content synthesis is weak or missing. References are included but not according to the Discussion instructions. 15 points |
Initial post is more than one day late.
Initial post much fewer than (500–750 words). Few components of the initial post requirements are addressed. Course content synthesis is missing. References are not included. 10 points |
25 |
Peer Replies | On time.
There was substantial evidence and synthesis of course content utilizing course topics and the introduction of questions and new information. Replies are 200–400 words. References are included according to the Discussion instructions. 25 points |
On time. There was some evidence and synthesis of course content utilizing course topics and the introduction of questions or new information.
Replies are 200–400 words. References are included according to the Discussion instructions. 20 points |
There was either some synthesis of course content or the introduction of questions or new information.
Replies are less than 200 words. References are included but not according to the Discussion instructions. 15 points |
There was little or no evidence of course content utilizing course topics or the introduction of questions or new information.
Replies are less than 200 words References are not included. 10 points |
25 |
Frequency of Contribution | Initial post with two peer replies posted on two separate days.
25 points |
Initial post with two peer replies posted on the same day.
20 points |
Initial post with one peer reply.
15 points |
Only initial post submitted or only replied to peers.
10 points |
25 |
Organization, Writing Mechanics, and APA Format | Clearly organized, no or limited writing mechanics and/or APA errors.
25 points |
Clearly organized, few to some writing mechanics and/or APA errors.
20 points |
Poorly organized, several to moderate writing mechanics and/or APA errors.
15 points |
Poorly organized, many writing mechanics and/or APA errors.
10 points |
25 |
Total points | 100 |