The Case Study Tulsa Memorial Hospital (SoonerCare)

Question 1

What reimbursement method would you recommend for each of the following providers? Be sure to justify your answers.

a. Primary care physicians

b. Specialists

c. Hospital

d. Others

Question 2

What allocation of premium dollars do you recommend for each provider? Be sure you justify your recommendations.

Question 3

a. What proportion of the premium dollar would you allocate to the professional services risk pool?

b. How would you split the professional services risk pool between primary care physicians and specialists?

c. What proportion of the premium dollar would you allocate to the inpatient services risk pool?

d. How would you split the inpatient services risk pool of the hospital?

Question 4

Conduct a sensitivity analysis. More specifically, using your allocation of the premium dollars, how does the total budgeted reimbursement compare with the total actual reimbursement to primary care physicians, specialists, and the within-system hospital?

a. if actual payments equal the premium allocation?

b. if both specialist and hospital payments are 10 percent greater than the premium allocation?

c. if both specialist and hospital payments are 10 percent lower than the premium allocation?

d. Do the risk pools provide appropriate incentives to the primary care physicians and the specialists?

Question 5

a. What are some reasons in favor of forming subpanels of the PHO's primary care physicians to handle only Plan patients?

b. What are some reasons against forming subpanels of the PHO's primary care physicians to handle only Plan patients?

c. Should subpanels of the PHO's specialists be created to handle only Plan patients?

Question 6

Consider some other actions that the PHO could take to ensure that its contract with the Plan is successful. Specifically, comment on the advisability and feasibility of taking actions in the following areas:

a. Utilization review

b. Quality management

c. Information system

Question 7

In your opinion, what are three key learning points?

Healthcare Financial Management