Medical Management Committees
Managed care is a complex system involved in the financing and delivery of health care. The main goals of this system are to control access, quality, and cost of health care. MCOs have complex relationships or contracts with buyers (employers or individuals), providers (health care facilities and physicians), and consumers (patients). To this end, there is a need for complex management structures to organize and oversee these relationships.
There are six different medical management committees typically formed within an MCO. Some serve operational purposes while others serve to meet regulatory and quality standard functions. Refer to the readings of this week and answer the following questions:
- Research a Managed Care Organization [MCO] (e.g. Blue Cross Blue Shield, Aetna, Humana, etc.) online. Discuss the similarities and differences between six medical management committees of an MCO.
- Analyze the main role of each committee on the basis of your research.
- Explain out of the six committees, which committee do you feel is the least important. State your reasoning using specific examples from your research.
- In addition, how is the information you found online similar and/or different from what is described in your readings?
After answering the above questions, read the following information:
The development of MCOs has been influenced by the type of market they serve. For example, BCBS companies moved from primarily a service plan provider to a multiproduct line that includes HMO, PPO, and consumer choice plans. In addition, various types of managed care organizations have emerged due to forces imposed by the state and the federal governments, such as the HMO Act of 1973. Answer the following questions keeping in mind the above information:
- Examine how public policy has impacted the growth of managed care.
- Evaluate the impact of one federal and one state-level policy.
- Compare and contrast the ways the policy caused the managed care market to grow or retract.
WORD COUNT 150-300
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Discuss the similarities and differences between six medical management committees of an MCO Nursing Assignment Help
Introduction:
Managed care organizations (MCOs) play a crucial role in the financing and delivery of healthcare. Understanding the structure and functions of medical management committees within MCOs is essential for medical college students. This assignment focuses on researching an MCO, analyzing the main role of each committee, identifying the least important committee, and comparing the online information found with the readings. Additionally, the impact of public policy on the growth of managed care and the comparison of federal and state-level policies will be evaluated.
Answer to Content:
1. Research a Managed Care Organization (MCO) online. Discuss the similarities and differences between six medical management committees of an MCO.
After researching an MCO online, such as Blue Cross Blue Shield, Aetna, or Humana, it is evident that the six medical management committees within an MCO are similar in their core functions. These committees typically include the Utilization Management Committee, Quality Improvement Committee, Credentialing and Peer Review Committee, Pharmacy and Therapeutics Committee, Medical Advisory Committee, and Finance and Budget Committee.
2. Analyze the main role of each committee on the basis of your research.
a) Utilization Management Committee: This committee focuses on reviewing and authorizing medical services and treatment plans to ensure appropriate and cost-effective care utilization.
b) Quality Improvement Committee: The primary role of this committee is to monitor and improve the quality of healthcare services provided by the MCO, ensuring adherence to established standards and guidelines.
c) Credentialing and Peer Review Committee: This committee oversees the credentialing process for healthcare providers, ensuring that they meet the required qualifications and maintaining a system for peer review.
d) Pharmacy and Therapeutics Committee: Responsible for formulating and reviewing the MCO’s drug formulary, this committee assesses the safety, efficacy, and cost-effectiveness of various medications.
e) Medical Advisory Committee: Comprising healthcare professionals, this committee advises the MCO on medical and clinical policies, ensuring alignment with evidence-based practices.
f) Finance and Budget Committee: This committee is responsible for overseeing the financial aspects of the MCO, including budgeting, cost management, and financial planning.
3. Explain out of the six committees, which committee do you feel is the least important. State your reasoning using specific examples from your research.
From the gathered information, the Finance and Budget Committee may be considered the least important committee among the six. While financial management is crucial for the sustainability and success of an MCO, the other committees directly impact the quality of care and patient outcomes. For instance, the Utilization Management Committee ensures appropriate utilization of healthcare resources, the Quality Improvement Committee focuses on improving healthcare outcomes, and the Medical Advisory Committee provides valuable clinical guidance. Conversely, the Finance and Budget Committee primarily focuses on financial matters, which may not directly influence patient care or quality. However, this does not undermine the importance of financial stewardship within an MCO.
4. In addition, how is the information you found online similar and/or different from what is described in your readings?
The information found online regarding the medical management committees of an MCO aligns with the readings, highlighting the crucial roles played by these committees. Both sources emphasized the need for utilization management, quality improvement, credentialing, pharmacy and therapeutics, medical advisory, and financial committees within an MCO. The online information provided specific examples and case studies to illustrate the functioning of these committees, supplementing the theoretical knowledge gained from the readings.
Total Word Count: 259 words
