Healthcare Flow of Funds explained: Healthcare Entrepreneur Bootcamp

Agenda Managed Care 101 for healthcare entrepreneurs seeking to do business in the California market.

Healthcare flow of funds explained. Managed Care 101 for healthcare entrepreneurs seeking to do business in the California market. Session led by Alex Yarijanian, CEO Carenodes. The aim: providing healthcare entrepreneurs with a framework within which they will find their place in the business value chain.

No business doing business in healthcare.

No business doing business in healthcare if you don’t know healthcare business. With that said, you shouldn’t limit yourself because you might have value to contribute. But it should worry you because you don’t have the time necessary to gain tribal, on-the-job, healthcare know-how and work experience.

This session challenges the idea that, just because you don’t have healthcare experience, you can’t learn if knowledge is transmitted in uniquely effective styles and methods.

Providing healthcare entrepreneurs with a framework within which they will find their place in the healthcare business value-chain.

Crossing the Chasm of Healthcare Startups: Reduce go-to-market time by understanding your leverqage points vis a vie industry meta-dynamics and insider insight. Bend the learning curve that surprises, paralyzes, and discourages many health technology startups.

Session Notes

A PILOT

Crossing the Chasm of Healthcare Startups: Reduce go-to-market time by understanding your leverage points vis a vie industry meta-dynamics and insider insight. Bend the learning curve that surprises, paralyzes, and discourages many health technology startups.

Managed Care Boot-camp for Healthcare Entrepreneurs, was a ‘pilot’ session designed to impart otherwise difficult to synthesize knowledge. Given its ‘pilot’ nature, please excuse instances where your experience might be interrupted by factors such as difficulty in whiteboard visibility, etc.

BOOTCAMP SESSION EXPERIENCE & OUTCOMES

Everyone should be able to walk out of this session feeling empowered by having learned the basic flow of funds (starting at the payer) and reimbursement structures along the healthcare delivery value chain. 

Managed Care Boot-camp for Healthcare Entrepreneurs, a ‘pilot’ session designed to impart otherwise difficult to synthesize knowledge with the following objectives:

1. Bend the learning curve of entrepreneurs in healthcare
2. Provide a framework to contextualize health tech business models (aim: to help provide a framework within which you will find your place in the business value chain).

You should be able to better refine your understanding of what ‘buckets’, and mechanisms, of funding you should pursue and trigger so as to index your business accordingly. Trends, current industry practices, and changes set to be effective in the future will be weaved into the session so as to contextualize the material. 

For an outline of topics covered, Managed Care 101 for healthcare entrepreneurs seeking to do business in the California market, see below.

to help healthcare entrepreneurs by providing a framework within which they will find their place in the business value chain.

otherwise, how else would you know how to price your deals and products?

Topics covered in this session are as follows:

I. Essential concepts
  • Crash course on 6 functional areas in any healthcare organization
    1. Operations: anything that hits P&Ls
    2. Compliance
    3. Network/Contracting
    4. Health Services: clinical services, medical director’s wheelhouse
    5. Quality: outcomes, QA/QI
    6. Engagement: outreach, customer services, etc.
  • Understanding Volume-to-Value drivers in payment
    • Business models for health technology companies
II. Managed Care Mindset: How to think like your customer.
  • Managed care: ‘utilization management’
  • Payment: Volume shift to value
  • Quality (‘value’) measured
    • Patient experience
    • Clinical outcomes
III. Lines of Business aka ‘LOB’ (funding source)
  • Medicare (Traditional Medicare and Medicare Advantage, Parts ABCD)
    Medicaid (managed Medicaid, state / federal, Medi-Cal)
  • Duals (Medicare and Medicaid beneficiaries)
  • Commercial (on exchange, off exchange)
IV. Products (benefit designs)
  • The spectrum of products: HMO, PPO, POS, EPO, FFS
  • Business ramifications
V. Difference between ‘LOB’ vs ‘product’
  • Difference between ‘LOB‘ (Medicare, commercial, etc) vs ‘product‘ (HMO, PPO, etc.)
VI. Main Reimbursement structures (payer/provider agreements)
  • Fee for service (FFS)
  • Value-based payment: upside, upside/downside
  • Predominate California Market Structure, determine who is at risk
    • Capitation
    • Delegation
  • Risk-based deals
    • Capitations and delegation of functions by the health plan to a third party
    • Global-risk, shared risk, dual risk.

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