HCS 451 Week 3

Topics: Health care, Management, Health insurance Pages: 8 (1514 words) Published: November 23, 2014


Vanessa Beckley
Risk and Quality Management Assessment Summary
HCS/451
November 10, 2014

Risk and Quality Management Assessment
What is a managed care organization?
Managed care organization is the entity which integrates the finance and delivery functions of health care. Managed care organizations are providers that put together health care finance and delivery, that is, they combine the payer arm of the health care system with the provider arm. This involves contracting with health care providers to deliver health care services on a capitates basis. MCOs employ utilization management techniques in an attempt to deliver quality care at lower cost than traditional systems (Managed care organization (MCO).

Centene Corporation provides health plans through Medicaid, Medicare and the Health Insurance Marketplace and other Health Solutions through their specialty services companies. Centene operates local health plans and offers a series of health insurance solutions. It’s contracted to healthcare organizations to provide services including behavioral health, care management software, correctional systems healthcare, in-home health services, life and health management, managed vision, pharmacy benefits management, and special pharmacies. (What We Do. n.d.). Retrieved from http://www.centene.com/who-we-help/) Medicaid-Low Income Families, individuals with disabilities and the elderly. Medicare-Medicare Advantage, Dual Eligible Special Needs, and Medicare-Medicaid Plans Health Insurance Marketplace also known as HIM- Ambetter plan provides educational tools and support designed to fit the needs and budget of the customer. (What We Do. n.d.). Retrieved from http://www.centene.com/who-we-help/) Purpose of Risk and Quality Management

Managed care entities and healthcare organizations main purpose and responsibility are to find ways to reduce risk and improve patient quality care. Risk management programs were developed to help the organization prevent risk and loss of revenue. Quality management ensures that an organization, product or service is consistent. Managed care, often seen primarily as a cost cutting initiative struggles to prove to the community at large that managing quality is as important as managing costs of healthcare. In managed care organization below are the main responsible and function of quality improvement ("Managed Care and Quality Management", n.d.).  Quality assurance (QA) is a systematic, departmental approach to ensuring a specified standard or level of care. Traditionally, it has focused on a few individuals' detecting and solving "special" problems. It uses methods to inspect performance, and repair or correct performance if it is below an accepted standard. The emphasis has been on identifying outliers or bad apples and taking steps to bring their performance in line with the norm ("Managed Care and Quality Management", n.d.).  Quality Improvement (QI) is a systematic, organization-wide approach for improving the overall quality of care - one that emphasizes performance improvement as well as a standard of care. It differs from QA in its scope, focus, approach and end result. The scope is organization-wide rather than in select departments. The focus is on identifying common causes and on processes, rather than on outliers and clinical outcomes. The approach is proactive rather than reactive. And QI's end result is to prevent errors and to improve rather than to inspect and repair problems and meet standards ("Managed Care and Quality Management", n.d.).  Quality Management (QM) is an all encompassing philosophy that permeates an organization's management infrastructure, policies and practices. It typically consists of five basic principles a focus on customer relationships; an importance on operational and care systems and the prevention of errors; the use of data-driven decision making; the active involvement of leaders and empowerment of employees; and,...

References: Managed care organization (MCO). (2001). In Pharmaceutical medicine dictionary. Retrieved from http://search.credoreference.com.ezproxy.apollolibrary.com/content/entry/pmd/managed_care_organization_mco/0
Managed Care and Quality Management. (n.d.). Retrieved from http://www.mcres.com/mcrmm03.htm
Quality Management. (n.d.). In Wikipedia. Retrieved from http://en.wikipedia.org/wiki/Quality_management
Silberman, P., & James, K. (2000). Quality Management in Health Care 
Risk Management. (n.d.). Retrieved from http://www.referenceforbusiness.com/small/Qu-Sm/Risk-Management.html
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