One of the primary issues in healthcare is medical costs. A proposed solution under the Patient Protection and Affordable Care Act of 2010 (PPACA) focuses on reducing the cost of care services while improving the quality of care. Over the years, managed care has been considered as an effective approach since it encompasses patient-centered coordinated care catered by payment incentives. I will use the staff model that encourages the care providers to attend to the patients’ needs per the state and the federal requirements. Here, the healthcare practitioners will be in charge of communicating with enrollees and informing them about the appropriate coverage. In my current organization, I designed the MCO and HMO based on a staff model that clarifies the terms of a contract, assesses the eligible enrollees, and enhances the continuation and coordination of care as means to meet the patients’ needs under PPACA.
In the proposed plan, the MCO and HMO will use a staff structure that encourages clarity in terms of the contract. Under the new model, the organization will use a specific language in managed care contracts so that patients can identify and establish the best option that attends to their needs (Honsberger et al., 2018). At times, there are conflicts of interest between patients and primary care providers concerning the cost of care and services delivered. This issue arises due to the difference in terms of care services between fee-for-service (FFS) and managed care (Park, 2019). The former allows patients to their preferred physicians and medical facilities while overlooking the accountability of health practitioners. Thus, the beneficiaries of managed care have insignificant appeal power when physicians fail to meet their health needs. However, under the new model, there will be clarity in the price mechanism and terms of the contract for different medical services.
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Apart from the language use and pricing system, the MCO and HMO will clarify the individuals covered under the Medicaid managed program. The plan will cover not only the older population but also children with conditions such as diabetes, asthma, and physical disabilities. This organization will use the staff-based model involving the primary care providers issuing comprehensive care services to the Medicaid beneficiaries and, in turn, receive payment on a per-member and per-month basis (Honsberger et al., 2018). The benefit of this approach is that the caregivers are accountable for meeting the federal and state requirements, including the new Patient Protection and Affordable Care Act (PPACA) of 2010. As a result, the chances of manipulating the beneficiaries will be significantly reduced.
Besides, the MCO and HMO programs will have a standardized assessment tool that is available in all the needed languages. Here, I will ensure that the contact information of the enrollees’ information is updated using the current technologies, including emails and smartphones, and the assessment forms are understandable (Honsberger et al., 2018). More specifically, the case management staff will conduct the assessments of the patients’ health conditions and determine the best care procedures that will improve their health outcomes. This information will then be entered into the electronic system, which uses a large set of data such as family history and vital signs to determine the appropriate medical procedure and charges (Price & Cohen, 2019). Although confidentiality is one of the primary concerns of the healthcare stakeholders, this organization will build a trusting relationship with the Medicaid beneficiaries to ensure that they understand the terms of the care services and data protection against third parties.
Furthermore, MCO and HMO will guarantee the continuity of care. The staff-based model will foster the transition of care from initial enrolment to discharge of patients from the healthcare organization. More importantly, there will be a system of coordinated care providers, regular therapy visits, and maintenance medications that will not affect the coverage and reimbursement (Honsberger et al., 2018). This approach not only appeals to the requirement of Medicaid but also fosters ongoing care management, whose goal is to deliver high-quality and cost-effective care. Thus, leadership and organizational capabilities will be restructured to eliminate the waste of resources and reduce the potentiality of patient harm (Enthoven et al., 2019). This goal will be realized through coordinated care for patients with different conditions. Primarily, the MCO’s plan will be a patient-centered approach that uses data to improve the care outcomes of enrollees upon discharge.
Moreover, the risk-based model will focus on care coordination that includes the integration of the services of the social workers, physicians, and nurse practitioners. Under the new structure, the MCO will evaluate the patients’ needs, develop a personal service plan, and connect the beneficiaries to it (Honsberger et al., 2018). The MCO will ensure that there is a coordination of care services and even intervene on behalf of the enrollees whenever it deems necessary. More specifically, the plan will focus on providing preventive care services. As a result, there will be reduced the probability of the number of rehospitalizations (Park, 2019). Improved communication between care providers will enhance the use of evidence-based practice and access to care.
Overall, the staff-based structure of the MCO and HMO will maximize the ethical delivery of care by clarifying the terms of the insurance contract, assessing the eligible persons, and continuing the coordination of care. This model will ensure that the patients’ right to autonomy is preserved since they will be allowed to read the terms of the contract before making decisions. Besides, the MCO will use modern technologies such as artificial intelligence to determine the patients’ conditions and the effectiveness of the medication to reduce the risk of rehospitalization. There will be also be coordinated care that involves the integration of healthcare practitioners in services delivery. The staff model will enhance the performance and effectiveness of MCO and HMO.
References
Enthoven, A., Fuchs, V. R., & Shortell, S. M. (2019). To control costs, expand managed care, and managed competition. Journal American Medical Association , 322 (21), 2075-2076. https://doi.org/ 10.1001/jama.2019.17147
Honsberger, K., Normile, B., Schwalberg, R., & VanLandeghem, K. (2018 April). How states structure Medicaid managed care to meet the unique needs of children and youth with special health care needs. The National Academy for State Health Policy . https://www.nashp.org/wp-content/uploads/2018/04/How-States-Structure-Medicaid-Managed-Care.pdf
Park, J. (2019). Medicaid managed care enrollments and potentially preventable admissions: An analysis of adult Medicaid recipients in Florida. International Journal of Healthcare Management , 1-10. https://doi.org/10.1080/20479700.2019.1692994
Price, W. N., & Cohen, I. G. (2019). Privacy in the age of medical big data. Nature Medicine , 25 (1), 37-43. https://doi.org/10.1038/s41591-018-0272-7
