Discuss the utilization management function in managed care

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Assignment: Do you understand the workings of health insurance in the United States?

A. Why were the first health insurance organizations formed in America? What were the original driving factors? Describe the early growth of health insurance in the US.

B. Explain the theory of insurance, by specifically addressing the degree of risk aversion, the size of the potential loss, and the "wealth effect".

C. What is meant by the "HMO Effect" versus "Favorable Selection" in managed care? Describe the evidence of an HMO Effect, and the evidence of Favorable Selection.

D. What are deductibles? Why are they so important in US health insurance models? How do changes in deductibles impact utilization and clinical decision-making.

E. Discuss the Utilization Management function in managed care, including Preadmission Certification and Concurrent Review of services.

F. Discuss the emerging role of Disease Management (DM) and Intensive Case Management in American managed care. How does DM actually work?

G. A key concept of health insurance is premium sensitivity. Describe the general process for premium computations in US healthcare insurance. Briefly explain employee premium sensitivity and how do employees typically respond to changes in health insurance premiums?

H. Describe the commonly used approaches to "underwriting" for healthcare services.

I. Do hospitals actually have "monopoly power" today? Why or why not?

J. Explain risk adjustment in the Affordable Care Act. How well does this approach work in your view?

Reference no: EM133836727

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