PHM Focus

Schedule at a Glance

Everything You Never Knew That You Needed To Know About Health Insurance

Primary Leader:
Paul Hain


Objective 1:
Differentiate among common insurance terms and apply them when appropriate

Objective 2:
Analyze hospital contracting, and contrast differing negotiating perspectives

Objective 3:
Distinguish among drivers of health care costs

Part one: understanding the terms and concepts behind the consumer side of healthcare:the differences among co-pays, deductibles, co-insurance and out of pocket maximums and how the Affordable Care Act changed the playing field. Additionally, different types of health plans offered (Health Maintenance Organizations, Preferred Provider Organizations, Narrow Networks, and High Deductible Health Plans). Part two: Explore hospital contracting with insurance companies. Walk through different leverage points, as well as map out what a typical contract dispute looks like. Additionally, analyze different ways that hospitals can get paid by insurance companies and the incentive consequences. Part three, separate the drivers of health care costs as well as the source of payments for those costs; differentiate among fully insured businesses, self-insured businesses, and the healthcare marketplace. Discuss commercial insurance carrier strategies to decrease the overall cost of care through structure (Accountable Care Organizations, shared shavings, and pay for performance) and consumerism (transparency tools, incentives, disease management).