Combined, DMC needs a minimum of $22 million per year to continue operations; therefore, it is necessary for DMC to significantly improve profit margins (Oxendine et. al. 2017). I recommend having DMC enhance their payer mix and increase patient volume. To begin, DMC needs to identify and eliminate the services in the hospital that are less profitable and instead utilize the service line methodology to ensure that all services are yielding a sufficient amount of returns. Moreover, DMC should look at the services that receive low reimbursement rates and find a way to capitalize in other services that they offer. To enhance the current payer mix, which is composed primarily of Medi-Cal and Medicare patients, DMC must identify the areas that need
...and his vision in successfully transforming the medical center to a tertiary care facility. However, in 2008 under Ron Henderson, the medical center expenses began to skyrocket and revenues failed to keep up. Also, a hospital census indicated that, on average, Medicare patients consisted of 58% and Medicaid patients consisted of 18% which caused the medical center to suffer from reductions in reimbursements. Although noted by solid evidence that utilization was experiencing a steep decline, Mr. Henderson added 127 new positions to the medical center. In 2009, Mr. Henderson was fired after the board of trustees realized that this financial bind of an $8.6 million deficit was caused by Mr. Henderson. In order for the new CEO, Richard Reynolds, to succeed at his new job title, he must create a benchmarking process adopting certain goals to remain a worthy competitor.
Membership Services (MSD) at Kaiser Permanente used to be a modest department of sixty staff. However, over the past few years the department has doubled in size, creating minor departmental reorganization. In addition the increase of departmental staffing, several challenges became apparent. The changes included primary job function, as well as the introduction of new network system software which slowed down the processes of other departments. These departments included Claims (who pay the bills for service providers outside of the Kaiser Permanente network), and Patient Business Services (who send invoices to members for services received within Kaiser Permanente). Due to the unforeseen challenges created by the system upgrade, it was decided that MSD would process the calls for both of the affected departments. Unfortunately, this created a catastrophic event of MSD receiving numerous phone calls from upset members—who had received bills a year after the service had been provided. The average Monday call volume had risen from 1,800 to 2,600 calls per day. The average handling time for each phone call had risen as well—from an acceptable standard of 5.6 minutes to an unfavorable 7.2 minutes. The department continued to be kept inundated with these types of calls for the two years that these changes have been effect.
Bigger hospitals increasing market share Loss of Medicaid and Medicare reimbursement Decline in revenue Loss of patients
To guarantee that its members receive appropriate, high level quality care in a cost-effective manner, each managed care organization (MCO) tailors its networks according to the characteristics of the providers, consumers, and competitors in a specific market. Other considerations for creating the network are the managed care organization's own goals for quality, accessibility, cost savings, and member satisfaction. Strategic planning for networks is a continuing process. In addition to an initial evaluation of its markets and goals, the managed care organization must periodically reevaluate its target markets and objectives. After reviewing the markets, then the organization must modify its network strategies accordingly to remain competitive in the rapidly changing healthcare industry. Coventry Health Care, Inc and its affiliated companies recognize the importance of developing and managing an adequate network of qualified providers to serve the need of customers and enrolled members (Coventry Health Care Intranet, Creasy and Spath, http://cvtynet/ ). "A central goal of managed care is containing the costs of delivering care, but the wide variety of organizations typically lumped together under the umbrella of managed care pursue this goal using combination of numerous strategies that vary from market to market and from organization to organization" (Baker , 2000, p.2).
In addition to this business plan, we must also address the financial issues plaguing this organization. To illustrate some of these issues lets look at some of the trends here at OCB and within our Industry: For example, OCB’s clinic operations profitability in 1990 was 60%, and now in 1996 our profitability is only 37%, which is down 23 percentage points! We can blame some of this on rising costs of overhead, consumables, etc, however this is happening as the industry as a whole is growing 5% annually, and as our customer base, largely senior citizens, population is growing at almost 1% as year. We should be capitalizing on these industry trends, however, as you all know, not all the trends work in our favor. For example, our lifeblood, the Insurance company’s managed care organizations, and government healthcare reimbursement programs shows a downward trend of allowable payments for our services (DRGs) For example in 1995 the DRG price of ...
The current health care landscape has been characterized by large scale consolidation and vertical integration of payers and providers. This has led to a handful of dominate players with substantial influence, and an increasing overlap in responsibilities between payers and providers. Although payers and providers have traditionally been on opposing sides, battling each other about quality of care versus cost-effective care, they are shifting to working together to achieve better value.
It is obvious that there is a large gap between where Coastal Medical Center is and where they need and want to be. When comparing CMC’s competitors, Johnson Medical Center and Lutheran Medical Center, CMC needs to provide more efficient, high quality care and focus on more profitable priorities instead of funding multiple unsuccessful projects such as the fifty-three unfinished developments.
Some critics have stated that there is not yet any quantifiable improvement in patient outcomes in comparison to the traditional model. Additionally some critics have voiced that some “practices may receive recognition without making fundamental change”.4 Another prominent flaw is the lack of funding to convert practices into PCMH. The cost to cut down patient flow, reconfiguring medical record systems, and get approval from insurers is more than many sites can handle financially. For the PCMH model to be accessible to some practices with the hopes of implementing such a program, capital funding would need to be made available from federal, state, and local entities. This limits many providers because many practices are not able to provide the necessary capital to start such a program. In addition to medical practices not having the necessary capital, providers must then work with a decreased patient load with the anticipation of possible reimbursement in the future.3 These points make it clear that the transition to a PCMH model would require hard work and commitment from the involved providers to make it
Medicare is a social policy many of our seniors look to for their stability when they reach 65
Formed in 1998, the Managed Care Executive Group (MCEG) is a national organization of U.S. senior health executives who provide an open exchange of shared resources by discussing issues which are currently faced by health care organizations. In the fall of 2011, 61 organizations, which represented 90 responders, ranked the top ten strategic issues for 2012. Although the issues were ranked according to their priority, this report discusses the top three issues which I believe to be the most significant due to the need for competitive and inter-related products, quality care and cost containment.
Competitive advantage matters greatly to those responsible for the management of healthcare institutions. Together with rapidly escalating healthcare costs, increasingly complex medical technologies, and growing regulatory and legal pressures, healthcare organizations face a critical need to improve the quality of care at reduced costs (Cu...
Medicare and Medicaid together "are the single biggest contributor to [the United States] long term [budget] deficit." This idea was expressed by President Obama during his 2011 state of the Union Speech. After saying this, the president said that health care costs need to be reduced, including these two services. Medicare and Medicaid are beneficial to those who receive their services, and the criteria for eligibility currently allow many to qualify for either program. This is most likely the cause of the major deficit that the president spoke of. However, downsizing or eliminating these programs to lessen the deficit will affect many people and their ability to receive healthcare.
Medicare and Medicaid are two of the United States largest broken systems, which must sustain themselves in order to provide care to their beneficiaries. Both Medicare and Medicaid are funding by a joint effort between the federal government and the local state government. If and when these governments choose to cut funding or reduce spending, Medicare and Medicaid take the biggest hit. Most people see these two benefits as one in the same, two benefits the government takes out of their pay check to help fund health care. While the government does deduct a sum from paychecks everywhere, Medicare and Medicaid are very two very different programs.
Medicare is the nation’s largest health insurance program. Generally, you are eligible for Medicare if you or your spouse worked for at least ten years in Medicare-covered employment and you are 65 years old and a citizen or permanent resident of the United States. Medicare-covered services include hospital insurance, inpatient hospital care, skilled nursing facility care, home health care, hospice care, and medical insurance (Medicare U.S.) With such an encompassing effect on the health insurance field, Medicare provides a haven for older individuals, and end-stage renal disease (ESRD) patients who require the best medical care for whatever possible reason. The only problem with this scenario is that doctors are turning many older patients away because they have Medicare. Why do doctors turn away Medicare patients? Is there a reason why certain doctors turn away certain patients?
Medicare and Medicaid are programs that have been developed to assist Americans in attainment of quality health care. Both programs were established in 1965 and are federally supported to provide health care coverage to vulnerable populations such as the elderly, the disabled, and people with low incomes. Both Medicare and Medicaid are federally mandated and determine coverage under each program; both are run by the Centers for Medicare & Medicaid Services, a federal agency ("What is Medicare? What is Medicaid?” 2008).