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15. (4 points) your cfo is considering hiring a medical management vendor that specializes in reducing physical medicine and chiropractor utilization. the cfo wants to test whether the vendor can lower hmo claim costs in 2005. the vendor states that they can reduce utilization for each of these two services by 8% and reduce costs by $3.00 per unit in 2005. without the program, medical unit cost is expected to increase from 2004 to 2005 by 10% and utilization by 2%. this program will also increase the disease management administrative costs in 2005 by 20%. using tables mc-4, mc-5, mc-6 (a) calculate the financial impact of this program assuming the medical management vendor’s assumptions are realized. show your work (b) list actions the plan and vendor should take to ensure compliance with their medical management obligations while minimizing their liability exposure. course 8: fall 2005 - 16 - go to next page managed care segment questions 15 – 18 pertain to the case study 16. (12 points) the bedford group is expanding into a new market and needs to contract with rural healthplans inc (rural), a physician health organization, to cover inpatient and physician services. rural is the sole hospital provider in this new market. rural does not provide skilled nursing services. to be competitive, your marketing manager requests a premium of $180 pmpm (excluding prescription drugs). your cfo requires a pricing margin of 3%. you are given the data in tables mc-1, mc-2, mc-4, mc-7, and mc-8. for developing 2005 expected claims costs for the new region: • assume there will be 120,000 member months. • hospital utilization for 2005 will be the same as the 2004 combined services for hospitals id 1, id 2 and id 3. • rural will be reimbursed based on the hospital id 2 fee schedule. • assume every rural admission is at least a two-day stay. • physician costs are expected to represent 45% of total medical costs. you plan to offer provider incentives: • rural will be offered an incentive similar to hospital id 2 except the target average length of stay is 90% of the expected average length of stay. • physicians will have a 20% withhold to be repaid three months after the end of the year. • any institutional surplus will be split with the physicians but will first be used to offset any withhold deficits. • for incentive purposes you have targeted utilization to be as follows: service admits/1000 days/1000 medical 25.0 80 surgical 15.0 70 psychiatric 4.0 40 alcohol & drug abuse 1.5 10 maternity 15.0 30 (a) list potential sources of data to supplement your own data and concerns you may have with each of these sources. (b) calculate the 2005 expected hospital inpatient pmpm claim cost for rural. show your work. course 8: fall 2005 - 17 - go to next page managed care segment 16. continued (c) calculate the hospital incentive that would be paid to rural for 2005 if they achieve targeted utilization. show your work. (d) calculate outpatient facility claims costs assuming you charge the $180 premium and using results from your prior calculations. show your work. (e) develop the physician withhold and hospital incentive liabilities at the end of 2005 assuming that actual incurred claims are $9 million for physician services, $10 million for institutional services, and that targeted utilization is achieved. use the results from your prior calculations. show your work. course 8: fall 2005 - 18 - go to next page managed care segment questions 15 – 18 pertain to the case study 17. (5 points) through provider profiling efforts, you observed that hospital id 2 performs an unusually high number of caesarian section (c-sections) deliveries. your discussions with this hospital resulted in an implementation of a new program that will lower their rate of c-sections by 10%. the one-time cost of this program is $50,000 which you have agreed to fund. in return, hospital id 2 will agree to change their reimbursement to a per case basis. you are given the following: • tables mc-2, mc-3, and mc-7 • incurred maternity claims at all hospitals were $7,800,000 for 2004. • incurred maternity claims at hospital id 3 were $800,000 for 2004. • prior to this new program, 30% of all deliveries at hospital id 2 were c-sections and c-sections cost 80% more than normal deliveries. (a) discuss the advantages and concerns when using inpatient claims data for quality improvement and utilization management purposes. (b) calculate the average cost per admit for c-sections and normal deliveries at hospital id 2. show your work. (c) calculate expected savings resulting from implementing this new program and changing reimbursement to hospital id 2 to a maternity case rate. show your work. course 8: fall 2005 - 19 - go to next page managed care segment questions 15 – 18 pertain to the case study   |
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