Why were the first proto-HMOs formed in America? What were the original driving factors in the HMO movement? Describe the preferred provider organization (PPO) model of managed care. Why do you feel that this is the dominant form of managed care today? Why do managed care organizations have a board of directors? What is the function of the board of directors? What is the role of a denial-of-coverage appeal committee in a managed care organization? And why is this function so crucial? What are meant by “outliers” in hospital reimbursement? How do outlier cases impact reimbursement to a hospital? (Points : 20) What are the three basic categories of utilization management? Provide a brief description of each category. What is meant by large case management (LCM) under managed care? Provide some specific examples of this type of case management. Discuss tools for changing physician behavior. Provide specific examples and perspectives on what will work best for changing behavior. What is meant by flow-down clauses in managed care contracts? Provide some specific examples. What is a risk-sharing arrangement in a managed care contract? Why might such an arrangement be beneficial to the parties? Cite and reference if use APA format.
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