The provider-sponsored Yellowstone Community Health Plan in Billings, MT, has discovered success by breaking many of the traditional rules in setting up a capitated insurance product. Key is to hold all parties accountable and to dissolve historic communication barriers.
Lagging HMO revenues and profits over the past few years have resulted in declining or stagnant reimbursement rates paid to providers nationally. Over the next year, however, average national premium rates are expected to rise, giving HMOs more financial flexibility and providers reason to be cautiously optimistic about possible increases paid to hospitals and physicians.
Direct contracts with self-funded employers are an often overlooked market for mature PHOs seeking additional covered lives. While such ventures often require additional PHO infrastructure, the financial rewards can be significant for those up to the challenge.
As states convert Medicaid into managed care, pediatric PHOs must change their operating dynamics to meet the challenges and take advantage of the emerging opportunities. One of the biggest questions these PHOs face is whether to start their own HMOs and risk alienating existing payers.
Electronic transfer of data within health systems and between offsite facilities, including payers, is becoming a cost-effective strategy for members of the Brookfield-based Wisconsin Health Information Network. The intranet technology is particularly well-suited for managed care because it generates even greater efficiencies and allows electronic communication between newly integrated health system partners.
Global packaging of medical services can potentially save physician-hospital organizations millions of dollars annually. Key is to aggressively involve physicians in structuring the program.
Global pricing is gaining in popularity as managed care payers look for efficient and innovative ways too provide care. Properly structuring global deals requires physician-hospital organizations to accurately define what services they are efficient at providing and also proving to the payer that they have the administrative and clinical ability to effectively manage global deals.
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