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Related Experiment Videos

A new physician's guide to evaluating managed care opportunities.

P Molloy1

  • 1Molloy & Co., Management & Planning Consultants, Manhassett, NY, USA.

The American Journal of Managed Care
|May 27, 1999
PubMed
Summary

New physicians and administrators can navigate managed care by understanding health maintenance organization types, utilization reviews, and risk-sharing. This guide helps in evaluating contracts for successful provider relationships.

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Area of Science:

  • Healthcare Management
  • Medical Economics
  • Provider Relations

Background:

  • Physicians and administrators frequently engage with managed care organizations (MCOs).
  • Evaluating and negotiating contracts with MCOs is a critical skill for healthcare providers.
  • Understanding MCO structures and policies is essential for successful practice management.

Purpose of the Study:

  • To review the major issues impacting medical practices during contractual relationships with MCOs.
  • To provide guidance for physicians and administrators evaluating and negotiating with MCOs.
  • To enhance understanding of MCOs' financial and clinical impacts on physician practices.

Main Methods:

  • Review of four major types of health maintenance organizations (HMOs) and their financial policies.
  • Outline of how utilization review and quality assurance policies affect physician practices.
  • Discussion of risk-sharing arrangements and their financial and clinical implications.

Main Results:

  • Identification of key financial policies across different HMO structures.
  • Analysis of the impact of utilization review and quality assurance on physician autonomy and income.
  • Explanation of various risk-sharing models and their potential benefits and drawbacks for providers.

Conclusions:

  • Informed contract evaluation requires understanding HMO types, financial policies, and operational impacts.
  • Physicians must consider utilization review, quality assurance, and risk-sharing when negotiating MCO contracts.
  • This review equips new physicians and administrators with essential knowledge for successful managed care negotiations.

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