Atlanta Georgia has a very diverse work force

Health Care: Manage Care Enrollment Scenario

Scenario Summary – Managed Care Plan Enrollment

Atlanta Georgia has a very diverse work force consisting of
men and women of various ages, ethnic groups, skills and education. Many people
live and work in one of approximately 14 counties that make up the Atlanta
region. It is not uncommon for an employee to drive close to 100 miles one way
to get to work. The employer base is diverse as well, consisting of large and
small employers ranging from entrepreneurs, health care services, local, state
and federal government offices, information technology, higher education,
landscaping, personal services, banking as well as the fast food industry. Now
that we have some background information learn more about the ABC Insurance
Company located in Atlanta.

The ABC Insurance Company has been very aggressive and quite
successful in recruiting companies, organizations, and individuals to join its
Managed Care Plans. Their ranges of services and rates have been extremely
competitive. Their employer base is spread out among the 14 counties, which has
been attractive to many employers. The ABC Insurance Company has been quite
successful in selling their managed care insurance program to employers and
organizations. So what was the issue?

Verde Greene Hospital has an excellent reputation for
quality in maternity care, cardiac rehabilitation, orthopedic medicine, and it
is the only hospital in town to have received the Magnet Award for Excellence
in Nursing. A sizable number of employer groups as well as employees, who have
insurance coverage with ABC Insurance Company, want Verde Greene Hospital to be
included in the network as a participating hospital.

When the ABC insurance company approached Verde Greene
Hospital to recruit them as a participating provider in their Managed Care
Plan, Verde Greene Hospital was very delighted to be asked. In fact, the
Hospital’s overall response was quite positive. However there was one
contractual stipulation that Verde Greene Hospital needed prior to signing any
contracts and becoming a participating provider. Specifically, Verde Greene
wanted to be the exclusive provider of maternity and cardiac care for all
patients in the ABC Insurance Company network. No exclusivity, no deal.

Because so many employers had pressured ABC Insurance
Company to contract with Verde Greene Hospital, the insurance company agreed to
the stipulations, and had agreed to enroll Verde Greene as a participating
provider of care and an exclusive provider of cardiac and maternity services.
This contract is legally binding for both parties, and they are scheduled to
sign this contract in ten days.

It appears that the exclusivity clause in the contract may
have created several unanticipated problems such as:

This would mean that a patient, who may need cardiac or
maternity care, may need to drive 50 miles and pass 4 or 5 good hospitals in
the plan in order to get the care they needed at Verde Greene Hospital.

A number of Obstetrics and Gynecology as well as
Cardiologists who reside in one of the 14 counties do not have privileges at
Verde Greene Hospital, and have threatened to dis-enroll from the plan if Verde
Greene Hospital is the only hospital contracted to see their patients. Even if
these physicians were given hospital privileges, this would mean more staff
meetings and Emergency Department duty, at a hospital that is too far away.
These physicians have threatened to dis-enroll from the plan. The existing
staff physicians at Verde Greene Hospital objected to the loss of available
hospital space and time, as well as, the possibility of the loss of existing
patients to the new physicians. These physicians threatened to dis-enroll from
the plan.

The other hospitals in the managed care plan objected to the
loss of patients and threatened to dis-enroll from the plan, and to sue for
restraint of trade.

Your Assignment

What should the ABC Insurance Company do? Why? How?

What should Verde Greene Hospital do? Why?

What should the employers do? Why? How?

What should the patients do? Why? How?

Explanation & Answer

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