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How Healthcare is Paid for in the US and the Role of Managed Care

Brought to you by Healthfirst and the SUNY Downstate Office for Institutional Equity

Program Overview

In collaboration with Healthfirst and SUNY Downstate Office for Institutional Equity, the goal of the series, How Healthcare is Paid for in the US and the Role of Managed Care, is to introduce medical students, residents, and faculty to the current state of healthcare payment models in the United States, including:

  • How Medicaid and Medicare are structured
  • Healthcare payment models such as value-based care
  • The role of managed care organizations such as Healthfirst in the healthcare ecosystem
  • How healthcare quality is measured and why it is important
  • How health plans use data that providers submit to improve outcomes and health equity

Additional topics that affect practitioners directly will be covered, such as:

  • What is risk scoring and why is it important?
  • How CPT/ICD-10 coding is used and why correct coding is important


Target Audience

SUNY Downstate medical students, faculty, and residents who see Healthfirst members.


Event Registration

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Program Schedule (January to May 2025)

Date Topic Presenter / Video Replay
2:00pm - 3:00pm – Part 1: Healthcare Payment Models in the United States
Jan. 24, 2025 Course Introduction: Health insurance in the US: past and present state of healthcare payment Maja Castillo, MD, MHA Medical Director

Jan. 31, 2025 State Programs: How states fund healthcare-Medicaid, EP, QHP Errol Pierre, MPA, DBA, SVP State Programs

Feb. 7, 2025 Medicare: CMS and the health plan’s role in Medicare products Jen Cohen-Smith, SVP Medicare Programs

Feb. 21, 2025 Value-based payment and the Healthfirst model Lisa Jenkins, RN, VP Delivery System Engagement
Feb. 28, 2025 How Healthfirst works toward health equity. (Case examples include gene therapy and maternity program, 1115 Waiver) Paul Amajor, MD, MS-HSM, Maja Castillo, MD, MHA, Medical Director
2:00pm - 3:00pm – Part 2: Role of the Managed Care Plan in a Value Based Model
Mar. 7, 2025 Pharmacy: How medications are paid for in the health system Bhavesh Modi, VP Pharmacy
Mar. 14, 2025 Quality: How is it measured and why is it important in a health plan Michele Lebarr, Director Clinical Quality
Mar. 28, 2025 Analytics: Using analytics to promote health and equity in an MCO Sule Baptiste, AVP Data Science
2:00pm - 3:00pm – Part 3: General Health System Payment Issues
Apr. 4, 2025 What is utilization management and why do health plans do it? Daniel Halevy, MD, VP Senior Medical Director
Apr. 25, 2025 Policy: How health policy affects MCOs and how Healthfirst works with policymakers Kirsten Beach, VP Gov Affairs
May 2, 2025 What is risk scoring and why is it important to patient care? Matt Newton, Director of Risk Scoring
May 9, 2025 What is medical coding and why is it important? Seminar closing Q&A Session Sandra Monsalve, AVP Clinical Documentation & Coding Excellence/ Maja Castillo, MD, MHA Medical Director

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