AN INDEPENDENT SELF-STUDY MODULE

An Introduction to
Basic Managed Care Concepts

Target Audience: Perioperative Staff Nurses
#1.2 Contact Hours
ABSTRACT

Managed care is rapidly becoming the dominant form of healthcare delivery and financing in the United States. It has the ability to manage cost and quality of healthcare services, while balancing access to that care. Keeping up with the speed with which managed care is transforming local markets is difficult for even the most seasoned Hospital Administrator, much less the busy clinician. However, in order to prosper under managed care, every hospital employee, not just the senior administrative team, must understand the importance of managed care.
The purpose of this self-study module is to provide busy perioperative nurses with an understanding of basic managed care concepts in order to explain why and how dramatically managed care has impacted healthcare delivery, their hospitals and individual work environments.

Behavioral Objectives:

By completing this workbook, the perioperative nurse will be able to discuss how and why managed care has become one of the main drivers of change in today's health care environment.

After reading and studying this workbook, perioperative nurses will understand why it is important for them to assist their hospitals to succeed in today's rapidly changing and constantly evolving managed care environment.

The behavioral objectives for the nurse who completes this self-study program are:

• to discuss the basic concepts and terminology associated with managed care.
• to discuss the reasons why hospitals contract with managed care organizations.
• to describe actions that a perioperative nurse can take to assist with their hospital's financial success.

PART I:

WHAT IS MANAGED CARE?

How is managed care defined?
What has led to the growth of managed care?
What are managed care organization's objectives?

PART II:

DEFINITION OF REIMBURSEMENT METHODOLOGIES

Fee-for-service
Per diem
Case Base
Capitation

PART III:

EVOLUTION OF MARKET STAGES

Stage I
Stage II
Stage III
Stage IV

PART IV:

KEY STRATEGIC INITIATIVES

Integration
Reduce system-wide costs
Information Systems
Quality Customer Satisfaction

SUMMARY

PART V:

POST STUDY EXAMINATION

APPENDICES:

Appendix A : Common Types of Managed Care Organizations
Appendix B : Glossary of Terms
Appendix C : Bibliography