AHA 209 - Philosophy of Managed Care
Managed care is now mainstreamed in America's healthcare system and has changed the delivery of healthcare services. Individuals working in the healthcare arena need to understand the impact of managed care on patients and providers. This course will review the evolution of managed care, explore how it works, contemplate its future and discuss the ethical issues surrounding it today. The roles and responsibilities of the case manager will be investigated as well.
The topic of Utilization Review will also be introduced in this course. It is essential for healthcare facilities to be able to control and manage the use of their services to minimize the risk of financial loss. Utilization Review monitors and provides appropriate incentives to influence the use of heatlhcare services. Managed care and Utilization Review are tools to coordinate and measure the delivery of cost effective quality care and have the potential to achieve significant containment of healthcare costs, an essential outcome in our present health care system.
Upon successful completion of this course, students should be able to:
Describe key concepts of the philosophy of managed care.
Explain the shift from the fee-for service model to capitation.
Use the specific terminology related to managed care models.
Identify critical components in developing and implementing treatment plans.
Explain the function of critical pathways and disease management strategies.
Define the roles and responsibilities o f the case manager and or healthcare provider in client advocacy and eithcial decision making.
Trace the history and development of the utilization review processes.
Describe the reequirements for utilization review procedures in relation to payer organizations, Managed Care, Medicare, Medical Assistance and private insurers.
Examine the role of physician and other health care personnel in resource management.
List the various mechanisms used in the resource management process by payer and provider organizations.
Discuss the role of the health care manager in the utilization review process.
Lecture Hours: 3
Course Prerequisites: (ENG 050, REA 050) or ENG 099 or REA 075, MAT 050/060, or