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Rural Country has a population of 15,000, a small primary care hospital, and ten physicians , includ

Rural Country
has a population of 15,000, a small primary care hospital, and ten physicians
,
including seven general and family practitioners, an obstetrician, a
pediatrician, and a general surgeon All the physicians are solo practitioners
The nearest urban area is about 60 miles away in Big City, which has a
population of 300,000, and three major hospitals to which patients from Rural
County are referred or transferred from higher levels of hospital care
However, Big City is too far away for most residents of Rural County to use for
services available in Rural County

Insurance
Company, which operates throughout the state, is attempting to offer “managed
care” programs in all areas of the state, and has asked the local physicians in
Rural County to form an IPA to provide services under the program to covered
persons living in the county No other managed care plan has attempted to enter
the county previously

Initially,
two of the general practitioners and two of the specialists express interest in
forming a network, but Insurance Company says that it intends to market its
plan to the larger local employers, who need broader geographic and specialty
coverage for their employees Consequently, Insurance Company needs more of the
local general practitioners and the one remaining specialist in the IPA in
order to provide adequate geographic, specialty, and backup coverage to
subscribers in Rural County Eventually, four of the seven general
practitioners and the one remaining specialist join the IPA and agree to
provide services to Insurance Company’s subscribers under contracts providing
for capitation While the physicians’ participation in the IPA is structured to
be nonexclusive, no other managed care plan has yet entered the local market or
approached any of the physicians about joining a different provider panel In
discussion the formation of the IPA with the Insurance Company, a number of
physicians have made clear their intention to continue to practice outside the
IPA and have indicated they would be interested in contracting individually
with other managed care plans when those plans expand into Rural County
Insurance Company requests your legal advice about whether this network
formation is likely to be challenged by the federal government

Discuss whether the network described in the Problem would
likely be challenged by the federal government

 

1)
Why? On what legal basis?

2)
What would be your response to
a challenge?

3)
Would factors increase or
decrease your changes of a federal challenge?

Base
your discussion on material from the text and your own experience

Cite
sources when necessary

Remember
to write 350 words minimum in complete sentences

 

Book
used is: The Law of Health Care Finance and Regulation, Third edition, Hall,
Bobinski, &Orentlicher (Problem is
on page 560 in the book)

 

 

 

Apr 25 2020 View more View Less

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