Question
VIP-MD is a health maintenance organization (HMO) located in North Carolina. Unlike the traditional fee-for-service model that determines the payment according to the actual services
VIP-MD is a health maintenance organization (HMO) located in North Carolina. Unlike the traditional fee-for-service model that determines the payment according to the actual services used or costs incurred, VIP-MD receives a fixed, prepaid amount from subscribers. The per member, per month rate (PMPM) is determined by estimating the health care cost per enrollee within a geographic location. The average health care coverage in North Carolina costs $360 per month, which is the same amount irrespective of the subscribers age. Because individuals are demanding quality care at reasonable rates, VIP-MD must contain its costs to remain competitive. A major competitor, National Physicians, entered the North Carolina market early in the current year with a monthly premium of $317. VIP-MD wants to maintain its current market penetration and hopes to increase its enrollees in the current year. The latest data on the number of enrollees and the associated costs follow:
Age | Enrollment in Current Year | Projected Enrollment Next Year | Average Monthly Cost in Current Year | |||||||||
14 | 44,888 | 48,177 | $ | 11,147,072 | ||||||||
514 | 81,656 | 83,863 | 10,058,832 | |||||||||
1519 | 95,073 | 95,087 | 8,436,024 | |||||||||
2024 | 65,446 | 67,082 | 9,538,624 | |||||||||
2534 | 132,696 | 131,754 | 26,431,408 | |||||||||
3544 | 166,076 | 174,646 | 38,881,308 | |||||||||
4554 | 84,696 | 90,089 | 22,741,136 | |||||||||
5564 | 98,424 | 101,123 | 28,690,912 | |||||||||
6574 | 155,488 | 160,759 | 49,517,344 | |||||||||
7584 | 67,095 | 71,665 | 33,431,960 | |||||||||
85 years and older | 22,699 | 26,049 | 24,285,675 | |||||||||
1,014,237 | 1,050,294 | $ | 263,160,295 | |||||||||
Required:
1. Calculate the target cost required for VIP-MD to maintain its current market share and profit per enrollee in the current year.
2. Costs in the health care industry applicable to VIP-MD and National Physicians are expected to increase by 7% in the coming year. VIP-MD is planning for the year ahead and is expecting all providers, including VIP-MD and National Physicians, to increase their rates by $25 to $342. Calculate the new target cost assuming again that VIP-MD wants to maintain the same profit per enrollee as in the current year.
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