Healthcare management
Describe the key elements of an information system for an MCO. What elements are different for a physician’s office or group?
Managed Care Organizations need IT, which they can utilize efficiently and effectively. The elements of IT that MCOs use include computerized provider order entry, E-prescribing, Personal health records, Telemedicine, Telehealth, and Electronic Medical Records (kongstvedt, 2019). An EMR is a digital system that keeps patient data and includes medications, personal information, payment methods, and accrued amounts for the health services delivery. The EMR can be used in any healthcare facility through customized software. MCO needs EMRs to keep patient information and provider information as well.
Amelung (2019) adds that MCOs contract with several providers for service delivery to MCO members. This means that an MCO system will have information on all the members, an element that a physician’s EMR will not have. The MCO will also have information on the payment patterns of the different MCO members, while a physician will have information that relates to itself only and the payment it receives from the MCO. Additionally, the physician’s EMR will contain finer details on patient illness and how it was managed, while that of the MCO will have more of an outline of the procedures carried out and for which it should compensate the physician.
Describe the technology that you think the MCO would need to operate fully.
Access to real-time data is necessary for enhancing performance and streamlining reporting. Programs that are value-based and that reward healthcare providers with incentive payments for care quality should be used. The technology used by the MCO will include the use of Healthcare Effectiveness Data and Information Set (HEDIS) along with state-specific criteria. This is because State Medicaid programs expect MCOs to be accountable for the quality of care against set-out measures (Singh, 2015).
The MCO will also need to have a Delivery System Reform Incentive Payment (DSRIP), which provides budget-neutral funding for states that will implement payment and delivery reform for Medicaid programs (Singh, 2015). Although different in structure, all programs tend to pin reimburse on the quality measures that the provider meets. The performance is determined by the events and clinical results that EHRs capture. The MCO will need to have clear and detailed clinical data captured in its system, which will help close the coding gaps under the value-based contracts. Because claims often are an under-representation of the health status for missing diagnoses and comorbidities, the ability of the system to capture the acuity more succinctly from the clinical data will have an effect on the actuarial calculations involved in setting rates, and this will ultimately drive revenue.
The success of the MCO will depend on the provider network’s success. To fuel this success, the MCO will need to have a system that shares comprehensive and timely information with the providers. When the MCO is capable of accessing data on patients and which spans throughout the network, then it will be in a better position to help its care teams to have a better understanding of their performance against goals and drive better overall performance for the network. To do so, the MCO will need to improve provider performance through information, processes, and tools to the provider from the payer. Thus, the MCO will implement benchmarks and dashboards for tracking KPIs and seeing where it can make real-time improvements.
Propose a specific electronic health record (EHR) that is Health Insurance Portability and Accountability Act (HIPAA) compliant. Describe the essential functions, costs, and projected savings for the MCO.
The EHRs will need to look good in that it provides easier, aesthetically pleasing, and more user-friendly interfaces. The EHR will need to allow for communication between the care providers and the payers. The information should be easily accessible. The current EMRs do not allow patients to have control over the persons who can disclose, use, and see sensitive data. The EHRs will need to comply with the ethical and constitutional rights of the patient as regards privacy. The portals should allow users to reset passwords for data protection. From the physician’s point of view, the patients should be able to log in and enter information such as their old records and insurance cards, which are invaluable pieces of information. This will allow patients to do more; the more they do, the less staff a physician needs to hire.
Providers are consumers of EMRs and who use the technology in care distribution. These need discrete data such as radio buttons where the pertinent data is separated and organized in a highly efficient way. The discrete data should be quantifiable, transferable, searchable, and operationalized. When this is made possible, then the physicians will focus more on health care’s human aspect.
The EHR will also allow payers to deal with risks linked to patients and payments. The main priority, which is also driven by monetary stability, should be as fiscally efficient as possible. Payers rely on the discrete information on the industry happenings and ought to have access to discrete, large health data from the population. While they are mainly data consumers, payers need to be in partnership with both small and large provider organizations so as to optimize value, as it is easier to take care of people who are healthy rather than caring for the sick.
Patients often do not need their data until when they are in a health crisis. When an adverse event occurs, it is important for easy access to information to be made possible and also capable of moving the data to different providers. Thus, EHRs should allow flexibility of data when it is needed. Additionally, the EHRs should have integrated health calculators that enhance provider and patient integration and create an extra platform for engaging patients. Hence, technology ought to facilitate care and not hinder the process.
Lastly, patients that use EHRs in in-patient hospital settings cost up to $730 less when treating patients compared to facilities that do not use EHRs (Kazley, Simpson, Simpson, & Teufel, 2014). While improved efficiency is a factor that contributes to savings, it also saves costs on supply needs, prescriptions, and tests. The EHRs software makes it easier and faster for staff to complete their tasks. EHRs also save communication time and allow for facilities to allocate the resources they have in a more precise manner. Instead of staffing employees to serve as clerks in the medical records department, persons in these roles can carry out these tasks; the EHRs software’s aim should be to improve the accuracy of information.
Strengths and Weaknesses of Insourcing Versus Outsourcing
According to Rivard and Aubert (2015), the main trade-off with hiring staff in the IT department versus outsourcing functions is that the organization will have greater operational control over staff though it will assume higher risks and costs. When IT is contracted out, it will allow the MCO to focus more on the core business. Additionally, the organization can get a wider employee contract base with a wide variety of technical competencies and thus not be exposed when an in-house staff leaves the practice, goes on vacation, or gets sick. Alternatively, the organization can train its staff even when the staff has little or no expertise rather than hiring new staff. Although this option costs much less compared to hiring full-time IT staff, the question remains whether it is worth training staff, especially when the organization is set to grow in complexity and size. The complexity of the IT structure that comes with an organization’s growth may become too difficult for the staff to manage in the future. Hence, it may be easier to choose to outsource a vendor that makes system support and training part of the costs of technology that the organization pays for.
In-house staff may be unable to solve network problems and similar challenges; hence, services such as telemedicine and interoperability should be given to contractual experts. The organization should seek to hire a vendor that is conversant with HIPAA issues, encoding messages, and cybersecurity issues, among others. With more labor-intensive functions such as the help desk, the organization may run up bills depending on the complexity, length, and number of calls. Other specific services that may be costly because of outsourcing include training staff, security checks including anti-virus scans, monitoring alerts, back-up, and hardware support.
Recommendation
This paper recommends that the MCO outsources its IT services as doing so will be more beneficial than it is costly. The organization will focus on its core business, and rest assured that the vendor will take care of any unforeseen IT issues. Also, with a HIPAA regulations conversant vendor, the MCO will not need to worry about data breaches. Outsourcing will mean cost reduction that follows a reduction in staffing numbers, fewer errors, and more efficiency in service provision.
References
Amelung, V. E. (2019). Insurance-Based Managed Care Organisations and Products. In Healthcare Management (pp. 49-66). Springer, Berlin, Heidelberg.
Kazley, A. S., Simpson, A. N., Simpson, K. N., & Teufel, R. (2014). Association of electronic health records with cost savings in a national sample. Am J Manag Care, 20(6), e183-e190.
Kongstvedt, P. R. (2019). Health insurance and managed care: what they are and how they work. Jones & Bartlett Publishers.
Rivard, S., & Aubert, B. A. (2015). Information technology outsourcing. Routledge.
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Question 
Healthcare management
The most important function of information technology (IT) for the managed care organization (MCO) is to support the business of the MCO, and how the IT department aligns with the operational dynamics of the MCO is a vital management consideration. A well-functioning IT department will help the MCO reduce risk (e.g., costs). The IT department should design, implement, and operate the systems that run the MCO. Efficiency is the hallmark of a good system.
Healthcare management
Your task as the manager of the MCO is to determine what the IT department in your organization should consist of, what its function will be, and what critical elements will be turned over to the IT department. Complete the following:
- Describe the key elements of an information system for an MCO. What elements are different than for a physician’s office or group?
- Describe the technology that you think the MCO would need to operate fully.
- Propose a specific electronic health record (EHR) or electronic medical record (EMR) program that is Health Insurance Portability and Accountability Act (HIPAA) compliant. Describe the essential functions, costs, and projected savings for the MCO.