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Managed Care Models

Managed care's level of control and relationships with medical service providers has been described on a continuum of control from the least controlled managed care model to the most restrictive as:

  • Tighter elements of control over health care delivery
  • More direct interaction with providers
  • Increased overhead cost and complexity
  • Greater control of utilization
  • Increased control on quality

The continuum of managed care models helps to understand the level of control for access, quality, and costs for each model. It is also true that managed care models are influenced by the market they serve. The geographic region impacts the design of managed care models. On the basis of what you learned in your readings of this week and the information provided in this assignment, answer the following questions:

  • Examine the importance of the continuum in understanding the differences among managed care plans.
  • Identify an MCO functioning in both your area and in some other parts of the country (for example, BCBS of California and BCBS of Georgia). Compare the organizations relative to the type of managed care products each offers.
  • Compare and contrast your findings with what you learned in readings this week.
  • If you were an employer looking for a managed care product for your employees, which of these three: HMO, PPO, or CDHP would you choose and why?

After answering the above questions, read the following information:

There are several key elements required in a physician's contract with an MCO. A typical contract between an MCO and a physician specifies the types of services offered, the number of members or lives covered in the plan, the standards and credentials needed to be maintained by the provider, and, of course, compensation. Utilize your readings and search the South University Online library or the Internet to answer the following questions:

  • Explain the key elements of the physician's contract.
  • Examine the common clauses and provisions of the physician's contract.
  • Explain the contract negotiation and credentialing process.

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