This week will discuss TRICARE and managed care workers compensation programs. Be sure to answer questions for both of these topics in your initial response to the Discussion Board.

TRICARE:

What are three health care options of TRICARE?

What is the role of a TRICARE PCM (Primary Care Manager)?

Workers Compensation:

Review the definition of managed care in Chapter 3, and also read page 619 before responding to the following:

List at least 3 benefits from incorporating managed care into workers' compensation programs.

Can you think of any disadvantages of having managed care incorporated into workers' compensation programs?

Should patients be able to choose their own doctor for workers’ compensation injury care?

Chapter 3 Definition of Managed Care

A managed care organization (MCO) is responsible for the health of a group of enrollees and can be a health plan, hospital, physician group, or health system. Unlike traditional fee-for-service plans, which reimburse providers for individual health care services rendered, managed care is financed according to a method called capitation, where providers accept pre-established payments for providing health care services to enrollees over a period of time (usually one year).

and page 619

Out-of-State Treatment

Billing regulations vary from state to state. Contact the workers' compensation board (or workers' compensation commission) in the state where the injury occurred for billing instructions if an injured worker presents for treatment of a work-related injury that occurred in another state.

WORKERS' COMPENSATION AND MANAGED CARE

Both employees and employers have benefited from incorporating managed care into workers' compensation programs, thereby improving the quality of medical benefits and services provided. For employers, managed care protects human resources and reduces workers' compensation costs. For employees, the benefits include:

• More comprehensive coverage, because states continue to eliminate exemptions under current law (e.g., small businesses and temporary workers)

• Expanded health care coverage if the injury or illness is work-related and the treatment/service is reasonable and necessary

• Provision of appropriate medical treatment to facilitate healing and promote prompt return to work (lack of treatment can result in increased permanent disability, greater wage replacement benefits, and higher total claim costs)

• Internal grievance and dispute resolution procedures involving the care and treatment provided by the workers' compensation program, along with an appeals process to the state workers' compensation agency

• Coordination of medical treatment and services with other services designed to get workers back to work (research by the Florida Division of Workers' Compensation suggests that managed care may reduce the time it takes an injured worker to return to work)

• No out-of-pocket costs for coverage or provision of medical services and treatment; cost/time limits do not apply when an injury or illness occurs

Case 7: Case Problem 5, p. 1088 (Mallor 16^th Ed. Chap 41): MeadWestvaco Corp. v. Ill. Dept. of Rev., 128 S.Ct. 1498 (2008).

Mead Corporation, an Ohio corporation in the business of producing and selling paper, packaging, and school and office supplies, also owned Lexis/Nexis, the electronic research service. Either as a separate subsidiary or as a division of Mead, Lexis was subject to Mead's oversight, but Mead did not manage its day-to-day affairs. Mead was headquartered in Ohio, while a separate management team ran Lexis out of its headquarters in Illinois. The two businesses maintained separate manufacturing, sales, and distribution facilities, as well as separate accounting, legal, human resources, credit and collections, purchasing, and marketing departments. Mead's involvement was generally limited to approving Lexis's annual business plan and any significant corporate transactions that Lexis wished to undertake. Mead managed Lexis's free cash, which was swept nightly from Lexis's bank accounts into an account maintained by Mead. The cash was reinvested in Lexis's business, but Mead decided how to invest it. Neither business was required to purchase goods or services from the other. Lexis, for example, was not required to purchase its paper supply from Mead and in fact purchased most of its paper from other suppliers. Neither received any discount on goods or services purchased from the other, and neither was a significant customer of the other. In 1994, Mead sold Lexis for $1.5 billion, realizing a capital gain of over $1 billion. Mead did not report any of this gain as business income on its 1994 Illinois tax return, taking the position that it was nonbusiness income and should be allocated entirely to Mead's domestic state, Ohio.

Coca-Cola's Internal Environment Coke's Value Chain- What does Coke do that adds value to the Coca-Cola Company The inbound logistics aspect of Coca-Cola is very strong as they have over 300 distribution or bottling centers across the globe serving to over 200 countries. Having many distribution facilities will minimize shipping time to decrease shipping costs and therefore increase revenue. A lot of research is put into the design and layout of the warehouse and other bottling centers. Since having intelligently laid out these warehouses, Coca-Cola has increased efficiency. Not only having inbound warehouses being effectively designed, Coca-Cola incorporates this layout technology in their outbound factories to increase their overall workflow design. Coca-Cola is one of the most recognizable brands in the world and continues to market their product extremely well. Coke's trademark value is estimated at a whopping $25 billion. The brand basically sells itself, but Coke is not just sitting back and being lazy. The Coca-Cola Company actively researches the needs of its customer segments and targets to provide drinks and snacks that people will want. As a luxury product, Coke understands that luxury items are the first things to go when times get tough. For this reason they provide excellent service to their suppliers and customers. Without excellent service, a beverage company will fall by the wayside as there are many other products out there to substitute any type of drink. 3 With over 500 brands owned by the Coca-Cola Company, there are many raw materials that are needed to support these snack and beverage brands. The main ingredient most of Coca-Cola's products is water. Coke understands the difficulties with many countries receiving fresh water and they work hard to deliver to these remote areas. Other than water, nutritive and non-nutritive sweeteners are used in their products. Coke has developed win-win relationships with their suppliers because both parties are in understanding that they will do a lot of business together. Coke does depend on one supplier for different ingredients they use. This could be dangerous for Coke as the supplier may take advantage of this relationship. The Coca-Cola Company is massive and has its own internal administration. These internal divisions include Human Resources, Information Technology, Accounting and others. They also spend millions of dollars a year on research and development of new products. Continually changing and understanding the needs and wants of the world's population will lead to happier customers and increased revenues. Required:

(a) Analyze this case and conduct a Value Chain Analysis (VCA) for Coca Cola Company.

b) Managing the value system for a global business like Coca Cola requires an organisation to make two broad choices. Discuss the two choices in light of the Coca Cola Company.

TRUE OR FALSE

4.    During the S portion of interphase the DNA making up each monad is duplicated, and the two sister chromatids remain together in the region of the dyad called the centromere.

5.__ Cytokinesis is the term used to identify the separation of the cytoplasm of an animal cell into two complete, separate cells through the action of microtubules, intermediate filaments and kinesin motor proteins.

6.__ Cells of both plants and animals have spindle fibers present during cellular division and these fibers are short microfilaments composed of the protein actin with associated myosin motor proteins.

7.__ Cytokinesis in animal cells undergoing mitosis might not occur and this results in the production of a cell with two nuclei, each with the diploid amount of monads present.

8.__ The process of cytokinesis in plant cells requires the correct function of myosin motor proteins and actin microfilaments.

9.__ Most fungi, animals and protists have a sexual life cycle that involves a clear representation of the alternation of generations.

10.__ Aneuploidies are usually the result of the nondisjunction of homologs during meiosis I or the nondisjunction of monads during meiosis II.

11.__ Most types (kingdoms) of eukaryotic organisms produce gametes as a result of meiosis of diploid mother cells.

12.__ Segregation of gene alleles occurs exclusively during the second meiotic division of plants and exclusively during the first meiotic division in animals.

13.__ When asexual reproduction occurs, the offspring produced have DNA from a single parental source and the offspring have less genetic variability than sexual reproduction.

14.__ The 23rd pair of chromosomes in humans are the sex chromosomes and females are heterogametic (2 types of sex chromosomes) while males are homogametic (1 type of sex chromosomes).

15.__ All members of the Plantae have both a multicellular haploid (gametophyte) and multicellular diploid (sporophyte) component of their sexual life cycle.

16.__The reduction division stage of meiosis is the second meiotic division (meiosis II) and this is when human cells go from a diploid state of 46 dyads to a haploid state of 23 monads.

17.__ A tetrad is composed of a homologous pair of dyad chromosomes that are involved in synapsis and crossing over may occur between homologous chromatids when the dyads are in this state.

18.__ A key function suggested for why organisms perform meiosis is as a mechanism of purifying selection and the removal of deleterious (mutated) genes.

19.__ The key event(s) in the transformation of organisms from the haploid component of their life cycle to the diploid component are the meiotic division of cells and production of gametes..

20.__ In female chickens you would find somatic cells with fully homologous pairs of chromosomes (monads) but in males there would be only mostly fully homologous pairs (monads) and one partially homologous pair the sex chromosomes.

The Case of the Phony PA

As a Senior Investigator at University Hospital, you were awarded a large grant to study the effects of new medications on healing leg wounds. The grant calls for either a nurse practitioner (NP) or a physician assistant (PA) who will be able to document the processes and keep the paperwork up-to-date on the grant. You interviewed several candidates and have found that Charles Tony, a PA, appeared to be the best candidate. His resume indicated that he earned a bachelor’s degree from a prestigious midwestern university, worked several years as an EMT, then went to PA school and earned an associate’s degree as a PA. He presented diplomas and copies of licensure certificates and had excellent recommendations from many reliable sources. This package was presented to you by the Human Resources Department. He was interviewed by several colleagues who would be participating in the study and was hired. He began work and appeared to be doing a good job. After a few months, some strange events started to occur. For instance, the locker he shared with one of the physicians was broken into. Multiple purchases were made on the physician’s credit cards in a very short time. Mr. Tony claimed his wallet had been stolen during that same incident. Other employees stated he was acting somewhat strange around them. He began dating an employee in the institution, then her apartment was broken into. At this point, no one was really suspicious, and Mr. Tony appeared to perform the functions of this job without any problems. Approximately 14 months after he was hired, he did not show up for work, did not answer his phone, and none of the records he was responsible for could be located. You contacted the HR Department and they began an investigation. To everybody’s surprise, you learned none of his credentials was actually checked back to their primary sources. When this check was completed after he disappeared, none of the academic institutions had ever heard of him. His references were all fraudulent. The police searched his apartment and found many missing pieces of University Hospital equipment. Mr. Tony was, however, nowhere to be found. It appears you hired a true pretender.

Discussion Question:

1.What are the facts in this case?

2. What errors were made in the hiring of Mr. Tony?

3. What are the merits of checking on the background of any employee, especially those entrusted with the care of patients in a hospital or clinical setting?. Whose responsibility is it to check the references?.

4.How could these events have been avoided?

5. Were there red flags that should have altered you to the problem earlier?

6. Provide a detailed plan for evaluation and verification of health care professional's credentials and recommendations to avoid this type of issue in the future.

Pharmaceutical companies are dependent upon the profits generated by the sales of their products to satisfy investors and fund the research and development of new products.   Only one out of every 15,000 substances that are researched will eventually become medicine. This end result may occur after approximately 15 years and $1.5 billion in associated costs.

However, these same pharmaceutical companies are hiking prices to unprecedented levels in some cases.

“Specialists in infectious disease are protesting a gigantic overnight increase in the price of a 62-year-old drug that is the standard of care for treating a life-threatening parasitic infection. The drug, called Daraprim, was acquired in August by Turing Pharmaceuticals, a start-up run by a former hedge fund manager. Turing immediately raised the price to $750 a tablet from $13.50, bringing the annual cost of treatment for some patients to hundreds of thousands of dollars.” New York Times, Sept. 20, 2015

Some price increases might be attributed to shortages, but others have resulted from strategic purchases of older drugs and converting them into “high-priced ‘specialty drugs.’”  New York Times, Sept. 20, 2015

Contrast the history of penicillin, arguably the most life-saving drug of the last century. The pharmacist Sir Alexander Fleming not only discovered penicillin – the antibiotic that has saved millions of lives – but also ensured that it was freely available to as much of the world’s population as possible. Fleming could have become a very wealthy man if he patented penicillin, but he understood the drug’s potential to overcome diseases such as syphilis, gangrene and tuberculosis meant it had to be released into the world to serve the greater good. On the eve of World War II, he transferred the patents to the US and UK governments, which were able to mass-produce penicillin in time to treat many of the wounded.

Unlike other developed countries, the United States allows pharmaceutical manufacturers to set drug prices. In some cases for rare diseases, there is only one medication available, and competition is thwarted by patent regulation.

In the article, Determining Value and Price in Health Care, Austin Frakt writes: “It’s hard to argue with the notion that how much we pay for a drug should be related to the value it provides. Hard to argue, that is, until you try to pin down whose value counts, what value means, or how much to pay for it.”

When we are dealing with human life and death, should pharmaceutical companies be able to set their own prices?   Should the government step in? Should the government grant patent protection to life-saving medication? Or should such medication be part of the intellectual public domain to help the most people (as in the case of penicillin)? How would ethicists approach this issue from a utilitarian, deontological or ethic of care perspective? How would economist Milton Friedman respond to the issue of outrageous drug prices?