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(TCO 1) Why were the first proto-HMOs formed in America? What were the original driving factors in the HMO movement?

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  1. (TCO 1) Why were the first proto-HMOs formed in America? What were the original driving factors in the HMO movement?
  2. (TCO 1) What is meant by indemnity coverage, and how does it change in managed indemnity?
  3. (TCO 2) What is the role of the executive director in a managed care organization? Could you see yourself practicing in this position at some point in your career? Why or why not?
  4. (TCO 2) What is the role of the Peer Review Committee in a managed care organization? And why is this function so crucial?
  5. (TCO 3) What are meant by “outliers” in hospital reimbursement? How do outlier cases impact reimbursement to a hospital?
  6. (TCO 3) Describe the use of evidence-based clinical criteria in managed care. Why is this process so important in managed care today?
  7. (TCO 4) What is meant by pattern review under managed care? Why do payers conduct pattern review, and what kinds of things might they identify during such reviews?
  8. (TCO 4) Discuss tools for changing physician behavior. Provide specific examples and perspectives on what will work best for changing behavior.
  9. (TCO 7) What is meant by flow-down clauses in managed care contracts? Provide some specific examples.
  10. (TCO 7) What is typically covered under “term, suspension, and termination” of a managed care contract?

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