Ecosystem Overview
The four major players in the Healthcare ecosystem.
What are Payers, Providers, Regulators, and Suppliers?
The three lines of business healthplans participate in.
What is Government Programs, Commercial/Group, and Retail?
The key reason healthplans are interested in creating care management programs.
What is lowered medical cost, and reduced premiums for members?
The two components which drive healthcare expenditure.
What is Price of Service, and Utilization of Service?
The two key costs for a healthplan.
What is Medical Expense/Loss, and Admin Expense?
Two of the eight key factors that drive providers to be part of a network.
What is access to larger patient base, financial stability, reduced administrative burden, compliance & risk management, quality assurance, cost saving, member satisfaction, and competitive advantage?
The two key impacts of Obamacare / ACA.
What is outlawing coverage denial based on pre-existing conditions, and creation of the retail healthplan market?
Names of three of the six major healthplans in the U.S.
What is United Healthcare, Cigna, Elevance, CVS, Kaiser, and HCSC?
The role of a PBM in the healthcare ecosystem.
What is coordination between healthplans and drug manufacturers to provide pharmaceutical benefits?
The percentage of the American Population insured through employers (+/- 5%).
Names of three of the six healthplan product categories.
What are Managed care, Prescription Drugs, Dental, Vision, and Ancillary?
The six steps from quote to card.
What is sales, group setup, contract plan & summary, member enrollment, ID cards, and billing?
The year did Blue Cross & Blue Shield merged.
When is 1940?
What is traditional indemnity?
The six steps in provider network management.