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Maria is a 34-year-old woman with who presents to a healthcare provider to establish primary care

Case Presentation

Maria is a 34-year-old woman with who presents to a healthcare provider to establish primary care and management of her diabetes. She was diagnosed with type 2 diabetes 3 years ago, and has a history of polycystic ovary syndrome and hypertension. She works as a pharmacy technician at a local pharmacy chain, and has been married for 1 year. She lives with her husband and recently moved to the area from across the country for better job opportunities. Her A1C 1 year ago was at the recommended goal of 7.0%. Her current medications include metformin ER 2000 mg daily, enalapril 10 mg daily, and a prenatal vitamin daily. She has no allergies, and does not smoke or drink alcohol. She has been checking his glucose levels at home once daily, and readings vary from 110 to 165 mg/dL. She walks for 30 minutes 2 days a week (her days off), as she feels she is on her feet enough when she is at work. She would also like a referral to obstetrics/gynecology, as she and her husband want to start a family in the coming year and are not using any contraception.

Vital signs are as follows: weight, 72.5 kg; height, 63 in.; body mass index, 29.5; temperature, 98.4°F; pulse, 84 beats/min; respiratory rate, 20 breaths/min; and blood pressure, 140/82 mm Hg.

Lab results are as follows: A1C, 7.6%; glucose, 155 mg/dL; sodium, 135; blood urea nitrogen, 19; creatinine, 0.8; total cholesterol, 186 mg/dL; triglycerides, 186 mg/dL; HDL, 44; and LDL, 104.

Case Analysis Questions

1. What is your overall assessment of Marla’s current diabetes management status?
2. What considerations should be made regarding Marla’s desire to get pregnant?
3. How should Marla focus her self-management activities prior to becoming pregnant?

Managed Health Care Capstone Project

MH684 Managed Health Care
(300 points total)
You should begin working on the capstone project early in the course. Each assignment provides a benchmark for completing this capstone in a timely manner while you work through each course lesson.
Overview:
You’ll be required to submit a 12-16-page report which answers the prompts for each lesson. In your report, make it clear which prompt your response pertains to. For example, separate your responses from the prompts in lesson one from your responses to the prompts in lesson two by adding a new heading. Be sure to specify the narrative that applies to each prompt within each lesson by preceding your response with the letter associated with each prompt. For example, your responses between the prompts for “A” and “B” in lesson one should be made easily discernible.
Lesson 1: Health Insurance and Managed Healthcare: Its Origins and Developments – (2 Pages / 30 Points)
A. Describe some reasons why hospitals, health systems, and health plans are increasingly employing physicians directly. (10 Points)
B. Describe an ACO and the Medicare Shared Savings Program, and how these can result in improved patient outcomes while also reducing costs. (10 Points)
C. Other than establish the creation of ACOs, identify and describe five provisions of the Affordable Care Act and their impact on the healthcare industry. (10 Points)
Lesson 2: Health Plans, Payers, Provider Networks, and Health Benefits Coverage – (2-3 Pages / 70 Points)
Describe the differences between an open-panel and closed-panel HMO. (10 Points)
Describe what essential health benefits are and why they may vary between states. (10 Points)
Identify and describe three different ways payer organizations are structured. (10 Points)
Identify and describe five elements of a typical payer-provider contract. Discuss some reasons why payers and providers would want to contract with each other. (20 Points)
Describe why provider credentialing is important, who’s responsible for credentialing providers, the documentation used in provider credentialing, and how credentials are verified. (20 Points)
Lesson 3: Provider Payment (2-3 Pages / 50 Points)
A. Identify and describe the standardized code sets mandated by HIPAA, as well as commonly used code sets that aren’t mandated. Explain why these code sets are important. (10 Points)
B. Describe what fee schedules and maximum allowable charges are. Explain what Relative Value Units are and how these are used to determine reimbursement. (10 Points)
C. In an effort to enhance price transparency, Centers for Medicare and Medicaid Services (CMS) finalized policies in late 2019 that require hospitals to establish, update, and publicize a list of their standard charges for the items and services they provide. This includes:
• Gross charge of an item or service that’s reflected on a hospital’s chargemaster
• Discounted cash price for individuals who pay with cash or a cash equivalent
• Payer-specific negotiated charge for all third-party payers for an item or service
• De-identified minimum negotiated charge, or the least expensive negotiated rate with a third-party payer for an item or service
• De-identified maximum negotiated charge, or the most expensive negotiated rate with a third-party payer for an item or service
Explain why some stakeholders fear that this final rule could lead to price fixing. (10 Points)
D. Describe the possible benefits and challenges that a provider or health system may have when engaging in a capitated contract with a health plan. (20 Points)
Lesson 4: Utilization Management, Quality Management, and Case Management (2 Pages / 40 Points)
A. Describe different ways that utilization can be measured or projected for outpatient and inpatient services and how these can be used to determine payment rates set between payers and providers. (15 Points)
B. Describe some reasons why it can be difficult to determine which drugs a health plan covers, and how this informs the creation of a formulary. Also describe the difference between an open and closed formulary. (10 Points)
C. Describe the three interrelated categories of quality management activities. (15 Points)
Lesson 5: Sales, Governance, and Administration of Payer Organizations (2-3 Pages / 50 Points)
A. Describe the differences in responsibility held by the board compared to the management or leadership team of a health plan. (10 Points)
B. Identify and describe four different mediums through which commercial health plans can sell their products. (10 Points)
C. Describe the three categories of eligibility for coverage in the commercial market. (10 Points)
D. Describe the process by which claims are processed and benefits are administered. (10 Points)
E. Describe some ways in which fraud and abuse can occur, and how these activities can be detected. (10 Points)
Lesson 6: Medicare and Medicaid; Health Insurance Laws and Regulations (2-3 Pages / 60 Points)
A. Describe the five major components that determine the payment rates of Medicare Advantage plans. (15 Points)
B. Describe the different responsibilities in the regulatory oversight of Medicare Advantage plans from the federal, state, and corporate level. (10 Points)
C. Describe how the payment rates of Medicaid managed care plans are determined. (10 Points)
D. Identify and describe four ways that states oversee and regulate managed care organizations. (10 Points)
E. Describe the federal government’s role in in overseeing and regulating managed care organizations, and why this presents challenges when federal laws conflict with state laws. (15 Points)

Healthy People 2020 Impact Paper

Follow the instructions

APA format

6-8 pages

5-7 scholarly sources

Counseling specialization and multidisciplinary teams

Write an essay about counseling specialization and multidisciplinary teams.

APA style format

2-3 Sources

5 pages