Insurance Case Study Analysis

Insurance Case Study Analysis

Payer Systems in the Case Study

Payer systems in the case study are health savings accounts (HSA), employer-based insurance providers, and Tri-City HealthCare Agency. Tax-advantaged accounts, known as health savings accounts (HSAs), can be used to pay for certain medical expenses (Glied et al., 2022). Individuals can contribute to their HSA account pre-tax dollars, which can be used to pay for medical expenses. The patient in the example paid for her recent trip to the emergency room, but the hospital stays out of her HSA account.

Health insurance plans offered by employers to their employees are known as employer-based insurance providers. Employers acquire these plans and provide them to their staff as a reward. In this instance, the patient made an online payment through the website of her employer-based insurance carrier.

Tri-City HealthCare Agency is a healthcare provider that offers medical services to patients. In this situation, the patient was responsible for paying Tri-City HealthCare Agency for her recent urgent care visit and hospital stay. She received a check from her insurance company instead of a direct payment to Tri-City HealthCare Agency. The patient was required to get in touch with the insurance company’s help desk agent and was told to mail the bill to Tri-City HealthCare Agency by herself.

These systems are integral components of the healthcare industry and are often used in combination to cover the cost of medical expenses. In the case scenario, the patient utilized her HSA account and employer-based insurance provider’s website to make a payment but needed help when her insurance provider sent her a check instead of sending it directly to Tri-City HealthCare Agency.

How Market Forces Have Influenced the Need for Integrated Delivery System

The integrated delivery systems used by the healthcare sector have been influenced by market factors (IDS). Market-oriented strategies, which promote competition among healthcare providers and insurers, define the healthcare system. The need to reduce costs, boost quality, and increase access to healthcare services is what spurs this rivalry. The healthcare market forces have led to the emergence of integrated delivery systems, which offer various healthcare services under one organizational umbrella.

One of the market forces driving the need for integrated delivery systems is the increasing complexity of healthcare services. The healthcare industry has become more complex by introducing new technologies, medical treatments, and healthcare services (Usak et al., 2019). This complexity has led to the fragmentation of healthcare services, making it difficult for patients to navigate the healthcare system. Integrated delivery systems have emerged as a response to this complexity, providing patients with a comprehensive range of healthcare services, including primary care, specialty care, hospital care, and ancillary services.

The transition from fee-for-service to value-based payment models has had an impact on the requirement for integrated delivery systems. The old fee-for-service payment model, where healthcare professionals are compensated for the volume of services rendered, is being replaced with value-based payment models, where providers are compensated for the quality and results of care. This shift has incentivized healthcare providers to work together and coordinate care to improve patient outcomes and reduce healthcare costs. Integrated delivery systems are well-positioned to meet these incentives. They offer a range of healthcare services under one umbrella, enabling them to coordinate care effectively and improve patient outcomes.

How the Insurance Company Describes the Payment Method it Uses For its Customers

The insurer may clarify that the payment system it uses for its customers is based on a combination of different payment kinds and payers in the healthcare industry. For example, in this scenario, the insurance provider utilized the patient’s HSA account to pay for her urgent care and hospital stay. However, instead of directly sending the payment to the Tri-City Healthcare Agency, the insurance provider sent a check to the patient, who was responsible for shipping the payment to the healthcare agency.

The insurance provider might further explain that this payment system is intended to offer clients flexibility and choice in their healthcare spending. By allowing clients to use their HSA accounts, the insurance provider enables them to take control of their healthcare expenses and make decisions about how they want to allocate their healthcare dollars. Additionally, by sending the payment to the patient rather than directly to the healthcare provider, the insurance provider can negotiate better rates with providers and save money on behalf of its clients.

It is also important to note that this payment system may only be effective for some of the insurance provider’s clients. For example, some clients may not have HSA accounts or need to familiarize themselves with how to use them to make payments. Additionally, requiring clients to handle the payment process can add a layer of complexity and inconvenience to an already complicated healthcare system. Ultimately, the effectiveness of this payment system will depend on various factors, including the specific needs and preferences of individual clients and the healthcare landscape in which the insurance provider operates.

The Most Important Regulatory and Legislative Impacts on Managed Care Organizations

The Affordable Care Act (ACA), which went into effect in 2010, has had the biggest legal and regulatory impact on managed care firms. The ACA has significantly impacted the healthcare industry, including managed care organizations, by implementing changes to insurance regulations and increasing access to healthcare for millions of Americans. The ACA has several provisions that affect managed care organizations, such as requiring insurance plans to provide certain essential health benefits, implementing minimum medical loss ratio standards, and forbidding insurance companies from turning down coverage due to pre-existing conditions.

The ACA also established the Health Insurance Marketplace, enabling individuals and small businesses to compare and buy health insurance coverage. The ACA also established several programs to improve the quality of care provided by managed care organizations, such as the Medicare Shared Savings Program and the Medicaid Managed Care Final Rule (Chernew et al., 2020). These initiatives encourage managed care organizations to deliver high-quality treatment while keeping costs in check.

The ACA’s numerous provisions intended to expand access to healthcare, enhance the standard of treatment, and reduce costs have had the most significant legal and regulatory impact on managed care firms. As the healthcare landscape evolves, managed care organizations must adapt to changes in regulations and policies to continue providing high-quality, affordable care to their patients.

How the Case Study Could Have Differed If the Patient Was Using Public or Social Insurance

If the patient in this case study were using public or social insurance, such as Medicare or Medicaid, the payment process would have been different. Firstly, the patient’s out-of-pocket costs would have been lower than a commercial insurance plan. Public insurance plans have lower cost-sharing requirements, such as deductibles and co-payments (Rasmussen, 2022). This means patients must pay less for their urgent care and hospital stays. Secondly, the payment process would differ because public insurance plans have contracts with healthcare providers to establish payment rates. The healthcare provider would bill the insurance plan directly, and the program would pay the provider based on the contracted rates. The patient would not need to pay upfront or use their HSA account to pay for services.

Lastly, the reimbursement process would also be different for public insurance plans. Instead of the insurance plan sending a check to the patient, the healthcare provider would receive the payment directly from the insurance plan. The patient would not need to take additional steps to ensure the healthcare provider receives compensation for their services. Overall, if the patient in this case study were using public or social insurance, the payment process would have been more straightforward, with lower out-of-pocket costs and no need for the patient to use their HSA account or send a check to the healthcare provider.

References

Chernew, M. E., Conway, P. H., & Frakt, A. B. (2020). Transforming Medicare’s Payment Systems: Progress Shaped By The ACA. Health Affairs, 39(3), 413–420. https://doi.org/10.1377/hlthaff.2019.01410./

Glied, S. A., Remler, D. K., & Springsteen, M. (2022). Health Savings Accounts No Longer Promote Consumer Cost-Consciousness. Health Affairs, 41(6), 814–820. https://doi.org/10.1377/hlthaff.2021.01954./

Rasmussen, P. W. (2022). The Importance of Getting the Affordable Part of the Affordable Care Act Right. Chest, 161(6), 1429–1430. https://doi.org/10.1016/j.chest.2022.02.028./

Usak, M., Kubiatko, M., Shabbir, M. S., Viktorovna Dudnik, O., Jermsittiparsert, K., & Rajabion, L. (2019). Health care service delivery based on the Internet of things: A systematic and comprehensive study. International Journal of Communication Systems, 33(2), e4179. https://doi.org/10.1002/dac.4179./

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Read the case scenario and answer the case questions:
Case Scenario
A patient is confused about how to make payments for a recent visit to urgent care and hospital stay. Her employer-based insurance provider’s website allows her to use her HSA account to make a payment online. She uses her HSA debit card to make the payment, but her insurance provider sends her a check instead of sending it to the Tri-City HealthCare Agency. After contacting her insurance help desk via the website, she is told to send the check to Tri-City HealthCare Agency herself. The patient asked the insurance provider’s help desk representative why they could not just make the payments for her. She is told about the various payment types and payers in the healthcare industry and how the market influences integrated delivery systems in the industry.
Case Questions

Insurance Case Study Analysis

1. Describe the payer systems mentioned in the case study.
2. Explain how the market forces have influenced the need for integrated delivery systems.
3. How might the insurance provider explain the payment system it utilizes for its clients? Explain if this method is effective or not for the insurance provider’s clients.
4. What has been the most significant legal and regulatory effect on managed care organizations?
5. How would this case study have differed if the patient was using public or social insurance?
The response to each question should be a minimum of 200 words. A formal essay structure is not required; differentiated responses to each question are acceptable.
Integrate two to four scholarly sources in the collective assignment.
Prepare this assignment according to the guidelines found in the APA Style Guide, located in the Student Success Center. An abstract is not required.