Describe the payer systems mentioned in the case study.

Health Care Industry Payer System

Different types of payers play a major role in health services delivery. Three major systems of payers are used in the health care industry: commercial insurance, government funded payers, self insured payers. Medicaid and Medicare are federally funded and serve individuals and seniors with lower incomes. Insurance companies, such as Blue Cross Blue Shield or Aetna, provide coverage to both individuals and employers. Self-insured payers are employers who provide insurance coverage to their employees and assume the financial risks of their employees’ health care costs (Cleverley & Cameron, 2020).

Market Forces and Integrated Delivery Systems

The healthcare industry has been impacted by market forces, such as rising costs and the demand for high-quality care. The integrated delivery system is a network of organizations and healthcare providers that provides coordinated, comprehensive care for patients. These systems include nursing homes, hospitals, and other home care agencies that provide coordinated care. In response to market forces, healthcare organizations have consolidated to create larger systems. This is aimed at reducing healthcare costs, improving patient outcomes, and enhancing the quality of care (Shortell & Wu, 2020).

The Payment Systems Used by Insurance Companies

Different payment systems are used by insurance providers for clients. Fee-for-service is one of the more common payment systems. It pays providers per service. FFS systems encourage providers to perform more tests and procedures. Costs can increase as a result. Insurance providers also use capitation. This is a payment system where providers of healthcare are paid an amount fixed per patient, regardless of services rendered. The capitation system encourages healthcare providers to concentrate on preventive services and reduce unnecessary services. Insurance providers may also utilize the pay-for-performance (P4P) system, where healthcare providers are paid based on their quality of care and patient outcomes (Scheffler & Arnold, 2021).

Impact of Legal and Regulatory Environment on Managed Care Organizations

A major legal and regulation change for managed care organizations has occurred since the Affordable Care Act was passed in 2010. ACA included several provisions aimed to improve access to healthcare while reducing costs. MCOs were required to provide essential healthcare benefits such as preventive care, mental health, and other services without any annual or life-time limits. Medical Loss Ratio requirements were also implemented by the ACA. MCOs had to spend 80% or more of premium revenues on medical costs, otherwise they would have to refund any difference back their customers (Milstead 2019).

Case Study Differences with Public or Social Insurance

Payment systems would be different if the patient had been covered by public insurance, such as Medicaid or Medicare. Medicaid and Medicare each have their specific payment methods, so the patient wouldn’t have been able to pay with her HSA debit cards. Medicaid is a FFS-based system that pays providers. Medicare, on the other hand, uses both FFS as well as alternative payment methods such accountable care groups (ACOs) or bundled payments. A limited number of health care providers accept Medicaid. This may also have made it difficult for the patient to access healthcare, particularly if they were using Medicaid.

Conclusion: The healthcare industry is characterized by different payment systems. These include government-funded payers as well as commercial insurers and self-insured payors. In order to increase the quality of healthcare and lower costs, market forces have driven the demand for integrated systems. Payment systems used by insurers include fee-for service, capitation and cap