Case Study 1 (Planning Class)

In the case of St. Luke and Saint Alphonsus it is obvious that St. Luke was prepared as healthcare transitioned from a fee for service model towards a value based model. St. Luke took advantage of care coordination strategy. It allowed them to coordinate care amongst their employed physicians. Although many physicians were not keen of the idea or felt pressured the bonuses that can be received by St. Luke due to decreasing health care cost and increased quality of care yielded to be positive. Care coordination especially in underserved communities is important. To maintain some level of competition Saint Alphonsus hospital should create an Accountable care organization (ACO). An ACO model is intended to reward quality of care. It involves integrating hospitals and health care providers. This includes private doctors’ offices, nursing homes, various specialties. Since St. Luke has their employed physicians bound to only sending referrals to doctors only employed by them this can be beneficial. The consumers that will be targeted are the Medicare consumers. Contracts can be made through various Medicare insurances who will provide you the members (Shortell, Casalino & Fisher, 2010). The goal would be to improve quality of care. This will release bonus to all hospitals and physicians involved.

2. What are the advantages to directing physicians’ referrals within one system of care? Disadvantages.

One advantages of directing physicians’ referrals is that it lowers the cost of those who have access. The goals of health insurances are to limit the cost. If the patient is referred to a doctor within network, the care or procedure given will be done at a discounted price. Other advantages include, patients can seek care within network and receive care at a faster pace. Furthermore, physicians within the network will have access to patient medical record. Having access to medical records will decrease any delay in care that can take place if the patient was out of network (Gaille, 2017). The disadvantages would include the lack there of to choose a physician you feel promotes the best quality of care. You will accrue higher out of pocket cost if you must seek care out of network. The insurance will typically not pay for the care (Gaille, 2107).

3. Why would cost (charges) increase if services are performed within a hospital setting versus an independent physician office?

The costs are more when services are performed within a hospital setting versus a independent physician office because the insurance must pay both the provider and hospital. The cost accrued by the independent physician office is the provider cost (Kacik, 2018).

4. How could virtual integration be used to coordinate care without raising fixed costs?

Virtual integration must have a common goal or a purpose. The common purpose must involve both provider and health insurance. This also includes standardization of the technology use such as a promotion of a Electronic health record. One of the vertically integrated structures are Accountable care organizations (ACO). Focusing on a capitated population health care based model will allow the coordination of care without the raising fixed costs (Waltson,2018).