Managed Care and Health Insurance

1. Discuss one of the key ways that a typical board can lower an organization’s risk profile. Consider the following questions as you post your initial response:
• Which function of the board is related to risk management?
• What are the obligations of the board?
• How do obligations differ in a for-profit versus a nonprofit organization?

2. Identify a situation that may make it difficult for health plans to develop and maintain a network. Choose one approach that a health plan might take to overcome this challenge and consider the following questions as you respond:
• Why do you feel your selected approach is the best option?
• How might your approach differ depending on the environment?
o A rural area
o A medically underserved area
o A community in which there is little competition among specialists

3. Discuss how utilization management may change in the future. Consider the following questions in your response:
• What are the existing challenges in utilization management that would evoke changes?
• What are the primary changes that will likely occur?
• Why do you think these changes are imminent?
• How will these changes impact medical care processes and outcomes?

4. Identify what you believe to be the most significant trend or change in the prescription drug benefit over the past 15 years. What impact do you feel this has had and to what degree do you think it will continue to have an effect?
5. What is the value of disease prevention? Provide an example of a disease prevention program (either within the U.S. or international). Include a discussion of how a health plan would accomplish the following:
• Implement a prevention program
• Monitor/measure a prevention program
• Modify a prevention program as a result of successes/failures

6. Identify and explain a key difference in marketing a managed care program to a for profit business as opposed to a nonprofit business.

7. There are a great many issues associated with adapting to local conditions that U.S. Managed Care Organizations (MCOs) abroad have had to face. Issues include:
• Lack of standardized coding systems
• Established lines of physician income that are threatened by managed care
• Cultural sensitivity
Explain which issue you believe poses the greatest challenge and discuss a strategy that could be leveraged to deal with this issue.

8. Each state is responsible for providing regulatory oversight for health insurance provided to its residents. Identify the state in which you live and explain some of the key regulations that it imposes on health insurance markets. This can include:
• Restrictions
• Prohibitions
• Guarantees





Sample Solution