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You Decide – Case Study Essay

HMO which stands for Health Maintenance Organizations are licensed health plans that place providers, as well as the health plans, with dealing with HMO’s there is a risk of medical expenses. The downfall with HMO is that patients must stay inside their network and if the go outside the network they will have to pay out of pocket expenses. HMO is very limited; many patients don’t like limitations when it comes to their decision about their health. PPO which stands for Preferred Provider Organizations provides patients any provider of their choosing.

It is known for PPO plans for patients to take advantage of discounts if they choose inside their network. The downfall with this plan, it can be costly if the patients go out of their network. The insurance company will pay 80% of the insurance and the patient is responsible for the remaining cost 20%. If the patient wants to go out of their network then the insurance company would have to pay half the cost and the patient will be responsible for paying the remaining costs. Indemnity insurance is when a policy based upon a fee scale, such a sliding fee, with minimum limits on healthcare costs.

The downfall is with this plan is the patients will get stuck with the bill which was not covered by the insurance company. Problem Identification: As reviewing Cooper-Pearson Sports Marketing Company, the company CEO, Mr. Donovan has told me that for the past two years he has lost fifteen key senior employees. Mr. Donovan states he believe one major reason he is losing his staff is because his company cannot afford to hire and train the best. He feels it is waste a time and money, especially if the companies have to hire new staff.

Fearing the in the short run the new employees will not stay with company. When doing the exit interviews, he noticed majority of the interviews with past employees, they would consistently mention leaving because of the lack of adequate or affordable medical insurance. When talking with former employee Daniel he stated he the Cooper Pearson Sporting Marketing was his first job right out of college and he looked at the company as family, but as years past has more obligations and the benefits didn’t fit his needs with the pace with economics.

Talking with Doulas who is potential employee, his enthusiasm for the company was incredible but unfortunately he has asthma and would have to visit his doctor on a regular basis. Douglas implied that there is limited medical insurance for his health care needs. Situation Analysis: By Organizations manage the quality of the services delivered by their network providers and facilities through a variety of means, including treatment record audits, satisfaction data, and the tracking of complaints, adverse incidents, and quality of care concerns.

Increasingly, managed behavioral health care organizations are expanding their quality measurement efforts to include patient safety considerations, evidence-based guidelines, treatment outcomes data, and objective measures, such as the Health Plan Employer Data Information being in business for ten years it is still a growing company and has potential of expanding. We have looked into manage-care physician credentialing is when company is seeking health care providers, the process must be conducted in a manner that meets the goals of managed care program.

There are some perks when it comes to physician that uses physician credentialing such as… •Better payment from insurance carriers, this will not be a burdened with need to drain patients pocket •Serving more patients which make physicians more reliable providers if they are listed in the Preferred Physician’s Group and avoid out of pocket expenses •Improving quality in healthcare which includes an extensive background check to avoid fraud. Liberty to choose the fee plan, this would be the best way for a physician to choose the best fee plan that will be profitable to them, they can get fee per service or do capitation fee model based on average number of patients served per month in network •Access to fee schedule which will determine the maximum reimbursement limit for different services and help send billing claims accordingly •Positive Marketing with thorough physician credentialing plan it can provide a positive marketing benefit to network, attract large number of members through cost-effective plans.

The benefit of prescription drug program to the employer and the employee is that employees can save money by going with generic medication, mail order, and lower copayments. Pharmacy benefit is a very important component in health care benefits and when optimize can contribute to clinical, economic and quality of life outcome of benefit to payers as well as members.

The importance of quality management indicator in quality management indicator in manage care programs are very essential to have basically to make sure the patient is satisfied, which is key to happy employees. Is it important to have quality assurance which makes sure records, tracking of treatment, are there are any complaints, any incidents and quality of care for the patients. Solutions:

Looking over the problem and analyzing the data, I came up with few solutions that might Cooper-Pearson Sport Marketing Company, that would keep the employees he have and attractive new employees, by changing the health care plan. I think the company should have an HMO but it should be better HMO and I believe the company should also let the employees choose if they want PPO or HMO. Both Manage Care Programs have their perks and it will be benefiting not only the employee but the employer as well.

If and when Cooper-Pearson Sports Marketing Company expands the company, they most definitely have to invest or least think about changing the health care insurance if they are going to keep their employees at the company and attract future employees. That is the only way to fix this issue with employees leaving because of the healthcare plan. The benefit of the employer improving the health care plan and implanting this in the plan is that employees would appreciate it and would want to stay and for the future employees would want to join the company.

If the employees and future know that Cooper-Pearson Sports Marketing Company are in an affordable prescription that would help many that are on daily medication, in the long run they will be able to depend on not only the company but their health care and not have to worry about their health. When employees know that there is a sense of quality management when it comes to their health care, they know the company have the health at best interest, the employees would know that they would be satisfied.


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