Unit 3 - Individual Project

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Feb 20, 2024

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UNIT 3 – INDIVIDUAL PROJECT 1 Unit 3 – Individual Project Kristine Cameron 01 December 2023 Systems in Healthcare: HCM632 Colorado Technical University
UNIT 3 – INDIVIDUAL PROJECT 2 Unit 3 – Individual Project This paper is intended to provide a detailed analysis of managed care, as well as discuss how it can facilitate the transferring of health services to outpatient healthcare. It will also cover transferring healthcare services to more affordable forms of healthcare services. I will discuss how access, financing, and delivery are all impacted, both positively and negatively, by conducting an in-depth analysis of managed care. Finally I will take a look at how the role of managed care has an involvement in the initiatives and a few of its contributions to public health. As we begin our discussion on managed care we need to begin by taking a look at what managed care really is. Managed care can actually be traced back to the late 1920s where physicians and hospitals were first paid for their provided services by the Blue Cross and Blue Shield (Schield et al., 2000). A system of medical provisions where the individual patients are authorized to pick their own doctor and hospital visits, all while having the cost managed by an outside corporation, is what managed care basically is (Rono, n.d.). Further analysis shows that there are three separate forms of managed care available to us. The three forms of managed care are: Health Maintenance Organizations (HMO): This form of managed care mostly only pays for healthcare within the patient’s own designated network. While the patient is limited to a smaller group of providers in a localized network, they usually end up paying less for their healthcare. Point of Service (POS): This form of managed care will usually pay more if the patient receives care within their network and is the most common of the three organizations.
UNIT 3 – INDIVIDUAL PROJECT 3 Preferred Provider Organizations (PPO): This third type of managed care is the one which allows a patient to select between an HMO and a PPO whenever they are in need of health care ( What Are 3 Different Types of Managed Care Plans?, 2022). Managed care definitely differs from its conventional insurance counter-parts. As we read above, managed care tends to place limitations and restrictions on which physicians, as well as which services, can be covered. Managed care can also limit the amount of visits the patient is allowed in a pre-determined timeframe (“read ‘Managing Managed Care: Quality Improvement in Behavioral Health’ at NAP.edu,” n.d.). On the other hand, most conventional insurance plans are sometimes referred to as fee-for-services plans due to the fact that they place very few restrictions on what physicians or services can be sought out by the patient or consumer. As we saw above, there are three different forms of managed care; Health Maintenance Organizations (HMO), Point of Service (POS), and Preferred Provider Organizations (PPO). While all of these are separate entities that fall under managed care, they each share a number of common characteristics: Each of these organizations make arrangements with the selected physicians in order to provide a specific set of health care services to those enrolled in the plan. There are explicit criteria and standards in place for choosing the physicians that will provide the services. Each of them maintains formal programs to ensure that quality assurance, quality improvement, and utilization review are the same across each of the organizations.
UNIT 3 – INDIVIDUAL PROJECT 4 Each of the forms of managed care offer financial incentives for its enrollees to utilize the physicians and services that are covered by the plan (“read ‘Managing Managed Care: Quality Improvement in Behavioral Health’ at NAP.edu,” n.d.). In addition to the three forms of managed care listed above, the national Library of Medicine lists a fourth such organization. This is the Exclusive Provider Organization (EPO) and allows those enrolled to select their own network physicians without having to have an established primary care doctor and possessing physician referrals (Heaton & Tadi, 2023). Under the provisions of this organization, all expenses that are incurred outside of this network are not covered. Now that we have discussed what managed care is, and how it facilitates the transfer of health services to outpatient healthcare, we will begin to discuss what impact managed care has had on the access, financing, and delivery of healthcare. For this portion of the discussion, we will be taking a look specifically on Medicaid managed care. Medicaid managed care is important to public health due to the fact that one in five Americans is insured by Medicaid and it also covers half of the births in the United States (Franco Montoya et al., 2020). Access to healthcare can be more of a problem than one might expect, even when it comes to Medicaid. We already know that most HMO networks limit a patient’s access to receive care from providers who are in a specific network. As of 2018, these networks “ require appointments with professionals to be scheduled within a specific time frame, while distance standards establish a maximum distance or time an enrollee must commute to receive specialty care ” (Franco Montoya et al., 2020). While this is not often a problem, the fact that some HMOs utilize an extremely narrow network plan is. Sometimes these networks are just not feasible for some patients, vastly limiting their access to health care. Medical services should ethically
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