1. The Business of Managed Care

2. Plan for Today Introduce section of course that focuses on plans Internal organization of an HMO Overview of managed care industry –As seen through Interstudy report Short team meeting

3. Plan module

4. HMO Organization

5. Functional areas Marketing and sales Member services Provider relations Clinical management Rating and underwriting (Finance) Operations Information management

6. For your functional area... Does your area focus on internal or external clients? List and explain your area’s main functions –HINT: See subheadings in Knight What other areas in the company does yours work closely with?

7. Finance – Rating and Underwriting Area X Internal External Main functions – Price products – Price groups – Monitor revenues, cost, profits – Works with –Marketing, Information Management

8. Information Management Area X Internal X External Main functions –Enrollment/eligibility –Claims and claims payment –Referrals –Hospital authorizations –Provider payments –Premium statements –Medical records –Member education Works with –Most everyone

9. Operations Area X Internal X External Main functions –Implementing workable and efficient processes –Streamline enrollment and eligibility processes –Premium collection and distribution (timing) –Pay claims accurately and on time –Claim adjudication (paid, denied, pending) Works with –Marketing –Provider relations

10. Clinical Management Area Internal X External Main functions –Referral authorizations –Pre-certification –Concurrent review –Case management Works with –Provider relations –Operations –Member services

11. Provider Relations Area X Internal External Main functions –Segregate functions of network development –Selecting, recruiting and credentialing providers –Negotiating and re-negotiating provider contracts –Terminating providers –Amending provider contracts Works with –Other providers

12. Member Services Internal X External Main functions –Member education –Demand management –Problem resolution –Member grievances Works with –Provider relations, marketing, financial services

13. Marketing and Sales Internal X External Main functions –Market research –Product development/teams/testing/implementation –Advertising –Marketing communications –Cooperative marketing –Sales Works with operations, member services, information systems

14. Overview of HMO industry 652 plans 78.8 million enrollees Enrollment grew 7.9% from 7/97 to 7/98 41.5% of enrollees in IPAs 59.8% of enrollees in federally qualified plans 36.3% of enrollees in nonprofit plans

15. Largest National Managed Care Firms The Blue Cross & Blue Shield Association (13.3 million) Kaiser Foundation Health Plan (8.4 million) United Health Care (5.6 million) Aetna US Health Care (4.3 million) Foundation Health Systems (4.2 million) 77% of national HMO enrollment

16. Largest plans by total enrollment Kaiser Foundation Health Plan of Northern CA Kaiser of Southern CA HealthNet - CA PacifiCare - CA California Care - CA

17. Largest plans by Medicare enrollment PacifiCare - CA Kaiser of No. CA Humana Medical Plan - FL Kaiser of So. CA Health Net - CA

18. Largest plans by Medicaid enrollment Triple-S, Inc. - Puerto Rico Tennessee Managed Care Network Human Health Plans - PR California Care Health Net - CA

19. HMOs in Pennsylvania Penetration rate is 30.9% –Just about the national average 22 plans

20. Pittsburgh, Pennsylvania 10 plans HMO penetration rate 25.5% HMO enrollment – 597,933 Keystone Health Plan West –Total state enrollment is 342,754 –For profit –Affiliated with Blue Cross and Blue Shield

21. Checkpoint #2 Show that you understand different types of plans, including differences and similarities Show you understand how and why different types suit different people Justify your choice by comparing it to other alternatives Demonstrate that you consulted provider directories