Health Care Maintenance System - Essay Example

"Health Care Maintenance System" is a great example of a paper on the health system. Health maintenance organization provides individual funded health care benefit plans and manages care for health insurance in the country. The health care maintenance system is based on fee-for-service costs. Adjusted average per capita cost (AAPCC) is the method used in computing these rates. The law that governs Medicare organizations stipulates that the capitalization rate is set at ninety-five percent of the costs per the traditional fee-for-service rates. However, the rates keep changing in every region. The change is due to the variation in the cost of medical services depending on the region the services are offered. Staff model is an example of a health maintenance organization. The model involves employing physicians who only serve the organization’s patients. The method is under the closed panel health maintenance organization. 

            The health services research team in the country informs the insurers, consumers, providers and the government official about health-related issues. They act as the primary health information source for the public. Individuals and families make choices depending on the information they obtain from the team. The health service research team is concerned with carrying out a scientific inquiry on financial, social, health and personal issues affecting health. The data collected is essential for the consumer in making the right choices.

Pay for performance and capitalization have both influenced the health care system in the country. The methods have generated many changes in the health maintenance organization too. Pay for performance aims at the raised quality of care and declining health care costs. Capitalization too has an advantage over the health maintenance system. It advocates for flexibility among the health practitioners in the provision of health care. It also provides incentives aimed at preventing illness in the future unlike health maintenance organizations, which only finances medical care for their patients (Santerre & Neun, 2012).

Response 1

            Sheffie's explanation that capitalization entails a provider paying a fixed amount of money for each enrolled individual is indeed correct. Global and partial capitalization models are used as payment methods in health care. I agree that the rate charged depends on various factors such as the total number for a provider, demographic and patient population. However, she has failed to mention the geographical location of the health facility. Charges differ in different parts of the country. Her explanation that health insurance payers obtain information through the recovery audit program is correct. The program identifies and corrects medical improper payment by detecting the overpayments and underpayments made by the consumers of health. In addition, the health service research team provides information that is important in dealing with claims made by the consumer.

Response 2

Latrina’s indication that global capitalization sets the rate for health maintenance organization is correct. The law that governs Medicare organizations stipulates that the capitalization rate is set at ninety-five percent of the costs per the traditional fee-for-service rates. However, the rates keep changing in every region. She explains that, an alternative method of payment impact on the level of risk management when taking on new risk or expensive patients. I agree that health maintenance organizations have to adjust in order to compete. Such financial risks are costly (Santerre & Neun, 2012). The health maintenance system has to come up with ways that will enable collaboration between the health providers and the patients. They should have future preventive plans for their patients and lower the cost of health in order to gain trust by most of their patients.

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