Question

DISCUSSION QUESTION 3-2

MH684 Managed Health Care

Lesson 3: Managed Care Reimbursement Structures

Upon completion of the Required Readings, write a thorough, well-planned narrative answer to the following discussion question. Rely on your Required Readings and the Lecture and Research Update for specific information to answer the discussion question, but turn to your original thoughts when asked to apply, evaluate, analyze, or synthesize the information.  Your Discussion Question response should be both grammatically and mechanically correct, and formatted in the same fashion as the question itself. If there is a Part A, your response should identify a Part A, etc.  In addition, you must appropriately cite all resources used in your responses and document in a bibliography using APA style.

Discussion Question 2 (25 points)

Discussion Question #2 is comprised of two parts. (25 points) (A 1½-page response is required for the combination of Parts A and B.)

Part A	If a hospital gets expensive care cases (i.e., high case-mix intensity, which will be discussed in more detail in the next assignment) and if the hospital has a choice of reimbursement methodologies, which method would be most advantageous to the hospital and why? Choose from per diem, DRG, or discount from charges. (13 points)
Part B	Which of the three (3) would be most advantageous to the MCO? (12 points)

Answer 1

Question 2:

Part A:

Discount from charges and a per- diem reimbursement payment made by the insurance providers.. per-diem reimbursement also contain a discounted charges..

Discount charges in health care provision with reduction, the per-diem reimbursement insurance provider changing based on the patient hospital stay and seeks treatment..it is a prospective payment system health care providers provide treatment and establish the cost of health care, insurance provider pays as per patient health based and the number of days the Patient received the treatment...

DRG or diagnostic related grouping, Medicare pays the hospital cost based on the patients DRG..if Hospital treats the patient spending less than the DRG payment Hospital get profit, if it is spent more than the DRG payment Hospital loses the money..

So Discount from charges is suitable payment model if a hospital gets high case-mix intensity to maintain hospital their current profit margin..If the prospective payment system (PPS) paid so average payment equally or less than cost and it will not proportional to costs, Hospital will not lose their profit and it refuse to provide care in DRGs were undervalued..The information about per diem cost which patient receive can be used to transform charges before in estimation in each care to produce cost- based weights..

Part B:

Managed care organization (MCO) focus on access, cost, Quality and effectiveness of health care services..

DRG payment models will be the most advantageous to the MCO.. Reimbursement from CMS pay Hospital for Medicare and Medicaid recipients. It provides value based reimbursement,it is a government health care programs can vary by state and program..managed care organization get benefit from DRG payment system to increased efficiency and transparency and reduce average length of stay..The reform of hospital payment system can provide substantial efficiency Benefit...it increase efficiency in inpatient care, management and to improve transparency in Hospital Activities..