Healthcare flow of funds explained.
Managed Care 101 for healthcare entrepreneurs seeking to do business in the California market. Session led by Alex Yarijanian, CEO Carenodes.
“Everyone should be able to walk out of this session feeling empowered by having learned basic flow of funds (starting at the payer) and reimbursement structures along the healthcare delivery value chain.
Managed Care Boot-camp for Healthcare Entrepreneurs, ‘pilot’ session designed to impart otherwise difficult to synthesize knowledge with the following objectives:
1. Bend the learning curve of entrepreneurs in healthcare
2. Provide a framework to contextualize health tech business models
My aim is to help provide a framework within which you will find your place in the business value chain.
You should be able to better refine your understanding of what ‘buckets’, and mechanisms, of funding you should pursue and trigger so as to index your business accordingly. Trends, current industry practices, and changes set to be effective in the future will be weaved into the session so as to contextualize the material.
• 6 functional areas
• Volume to Value
I. Managed Care Mindset
• Managed care: utilization management
• Volume shift to value
• Quality measured
○ Patient experience
○ Clinical outcomes
II. Lines of Business aka ‘LOB’ (funding source)
• Medicare (Traditional Medicare and Medicare Advantage, prts ABCD)
• Medicaid (managed Medicaid, state / federal, Medi-Cal)
• Duals (Medicare and Medicaid beneficiaries)
• Commercial (on exchange, off exchange)
III. Products (benefit designs)
• Spectrum of ‘utilization management’: HMO, PPO, POS, EPO, FFS
IV. Difference between ‘LOB’ vs ‘product’.
V. Main Reimbursement structures (from payer to provider)
• Fee for service (FFS)
• Value based payment: upside, upside/downside
• Predominate California Market Structure, determine who is at risk
○ Risk based (capitations and delegation of functions by the health plan to a third party): global-risk, shared risk, dual risk