Assignment Part 1:
You have recently been hired by a health system as a financial/operations analyst. This health system provides healthcare services across a dozen counties in the state. These counties include a large urban center and surrounding suburbs. In addition, these counties include a few smaller cities as well as rural areas.
While the health system's revenue is largely fee-for-service based, upper management is working to position the health system to thrive in a world where reimbursement models shift to value-based reimbursement or payment models where the health system has contracts for which financial success requires controlling the total cost of care for various patient populations. Specifically, the health system is considering entering an at-risk contract with the state's Medicaid program to provide care for a population of Medicaid patients.
The nature of the state Medicaid program is such that individual Medicaid patients can seek healthcare wherever each individual chooses. As such, they are not limited to receiving healthcare from your health system. The way the state determines the Medicaid patients for which your health system is financially at risk is based on where each patient received the largest fraction of their healthcare. This means you do not know the specific Medicaid patients for which you are responsible until after the fact (i.e., retrospective attribution). In the meantime, Medicaid reimburses healthcare providers on a fee-for-service basis, but once the attribution of patients has been determined, Medicaid compares the total cost of care for this population relative to a benchmark. If costs are lower than the benchmark, Medicaid splits the savings with the health system. If costs are higher than the benchmark, the health system must pay the State for half of the total cost of care above the benchmark costs.
You are tasked with preparing an evaluation of this opportunity for the executive team. What are the risks to entering this contract? What are the risks of not entering into this contract? You should consider the following as you answer these questions:
- Size of the Medicaid population you are likely to be at risk for.
- Size of your health system.
- The breadth of healthcare services you can provide within your health system.
- The share of the services you provide that go to Medicaid patients compared to all other insurance types.
Therefore, you must determine what are the crucial aspects that need to be covered. You must provide a clear recommendation and state why this is your recommendation. In addition to stating why you support this recommendation you must also address the cons to your recommendation. Note the purpose of this is to proactively address the likely concerns, but not discredit you recommendation.
Assignment Part 2:
The topic is Southside Community Clinics in Minneapolis Minnesota.
Develop a current Internal Environmental Assessment related to the selected challenge
- Current Mission, Vision and Values of the organization or department related to the challenge
- Any Key internal data sources and information or distinctive characteristics that might influence the strategic plan
- Conduct the internal part of the SWOT Analysis (ideally with those involved in the challenge) SWOT = (Strengths, Weaknesses, Opportunities, Threats)
Sources of Uncertainty (internal) (Note types of sources and Level of Risk = CT (Clear Trends, Unknown Knowables (UK) and Residual Uncertainties (RU)