Annotated Bibliography Summary

Managed care dominates health care in the United States. It is any health care delivery system that combines the functions of health insurance and the actual delivery of care, where costs and utilization of services are controlled by methods such as gatekeeping, case management, and utilization review. Different types of managed care plans came into development by three major factors. These factors include choice of providers, different ways of arranging the delivery of services, and payment and risk sharing. Types of managed care organizations include Health Maintenance Organizations (HMOs) which consist of five common models that differ according to how the HMO is related to the participating physicians, Preferred Provider Organizations

Throughout the last half of the 20th century, employers have acted on their own to regulate health costs by requiring employees to join health maintenance organizations (HMOs). More than 100 million Americans are under managed care. However, many patients and doctors complain that HMOs impose too many regulations and sacrifice healthcare quality. HMOs are undergoing a high level of scrutiny due to criticisms that the network is controlling and jeopardizing the healthcare system of the nation.

Managed care and its competition is being viewed to solve their issue on the struggle to control

Kleiner, B. H. (2012) Gives insight into conducted research to show how research of managed care has increasingly become a leading development in regards to the finances in managed

Managed Care is a complex healthcare system in which physicians, hospitals, and other healthcare professionals organize in an interrelated system of people and facilities that communicate with one another and work together as a unit, commonly referred to as a network. This network coordinates and arranges healthcare services and benefits for a specific group of individuals, referred as enrollees, for the purpose of managing cost, quality, and acess to healthcare. Managed care program may be provided in a variety of settings, such as Health Maintenance Organization (HMO) and Preferred Provider Organization (PPO). Managed Care Organizations (MCOs) performs three functions: (1) set up the contracts and organization of the healthcare providers who furnish medical care to the enrollees, (2) establish the list of covered benefits tied to managed care rules, and (3) oversee the healthcare they provide. Managed care greatly influenced the practice of medicine and that the enactment of the Affordable Care Act greatly affects managed healthcare planss (Beik, 2014). This paper will examine the future of managed healthcare delivery system under the Affordable Care Act provision to expand Medicaid program.

Those of us who have served in the Military a very familiar with managed care, we may not totally understand the concept of managed cared but are recipients of it daily. Unless there is a heated political debate about health care reform we usually don’t worry about health care reform. Health care cost is not something that we worry about; after all the government takes care of all our medical needs, even when we are seen out on the economy. The only time we might the troubles of health cost might visit our door steps occur when family members decided to see an out of network provider, we are them held accountable for paying medical bills. What I failed to realize during my time on active duty, Tricare is just another form of a managed care program. In this essay we will explore the history of managed care and Health Maintenance Organizations (HMOs). Additional, we’ll take a look at how managed came about, and the future of managed care and health care reform in the U.S.

Many have felt that the intentions of this new enactment were to prevent Americans from receiving the proper care that is needed. However, within managed care organizations is the ability to provide all those Americans with better and more affordable care. The formation of managed care organizations grew rapidly during the Great Depression, “not because consumers were demanding insurance against the risk of medical expenses or because nonphysician entrepreneurs were seeking to establish a business, but rather because providers wanted to maintain and enhance patient revenues” (Kongstvedt, 2). There was a major increase to company wide health care organizations when the government decided to enact the federal Health Maintenance Organization Act. This act “authorized start-up funding and ensured access to the employer based health insurance market” (Kongstvedt, 4). Many advocates of managed care organizations like to point out that, “managed care is unique in that it did not arise out of a specific legislative initiative but instead represents a market response” (Health Care Manager, 54). From this we are better able to understand that the wishes of consumers of traditional health care programs felt that something needed to be improved for success. Now that we know where managed care started, we can venture in to how it has evolved throughout the

When one examines managed health care and the hospitals that provide the care, a degree of variation is found in the treatment and care of their patients. This variation can be between hospitals or even between physicians within a health care network. For managed care companies the variation may be beneficial. This may provide them with opportunities to save money when it comes to paying for their policy holder’s care, however this large variation may also be detrimental to the insurance company. This would fall into the category of management of utilization, if hospitals and managed care organizations can control treatment utilization, they can control premium costs for both themselves and their customers (Rodwin 1996). If health care

The managed care plans are designed for medical care and dental care systems in similar design without considering that they are organized in an almost opposite manner. The medical care system is organized where 80 percent of physicians are specialists, and 20 percent are generalists. Whereas approximately 80 percent of practicing dentists are general practitioners who provide primary dental care and dentists own, equip and operate their own their dental offices without public subsidy. The managed care plans are used in medical care that has a larger capacity system (hospitals and physicians) than dental care system (there are not enough supply of dentists) making it easier to managed care companies to negotiate lower reimbursement rates for the promise of more patients in medical system

HMOs multiplied rapidly with the new federal giveaways. Managed care, now including PPOs, mushroomed. Employers initially perceived managed care plans as cheaper than traditional fee-for-service insurance. Gradually, they stopped offering a choice of health plans, making individual policies more expensive. HMOs' penetration of the industry had been subsidized into existence. Government had instituted managed care. Today, while overall quality of patient care remains the best in the world, doctors practice medicine in an increasingly intricate web of rationing and regulations: Physicians are stripped of professional autonomy. As patients wander the maze of managed bureaucracy, costs rise and quality deteriorates. Every American dependent on a third party for health coverage is a potential victim of managed care. And state sponsored management of medicine

The key aspect discussed in this paper will be managed care and its importance in relation to the overall Health Care development. Firstly, what is managed care? “Managed care is a mechanism of providing health care services in which a single organization takes on the management of financing, insurance, delivery, and payment” (Shi & Singh, 2017, p. 220). In order to understand how managed care has evolved, we must first look at the reason it was designed. During the 1980s and 1990s, the economy and working class Americans were faced with rising prices for medical care and services (Shi & Singh, 2017). Furthermore, health is considered as a form of capital simply due to the fact that it does not depreciate immediately (Aslan, Menegaki & Tugcu, 2016;2015). Disproportionate investments in areas such as health may negatively impact on growth and overshadow physical capital asset.

Managed care was established in order to manage health care cost, utilization, and quality (Kongstvedt, 2015). In managed care, health insurance is provided through HMO, PPO, and other types of managed care. It has the potential to reduced health care spending and improved the quality of care. However, despite of its success in improving the quality of care through preventive health care services, chronic disease management program, and so forth, many physicians are reluctant to be part of the managed care environment. Some of the reasons are the impact of managed care to physician’s income and autonomy. Under managed care, insurers have decreased the fees paid to physicians. There are different ways how managed care organizations control costs. One of this is through selective contracting with health care providers and hospitals to lower costs. In selective contracting, health care providers agreed to accept lower prices in exchanged for guaranteed volume of patients under managed care plan (Culyer, 2014). This paper will discuss more issues and trends in Managed Care Organizations such as the rise of Medicaid Managed Care spending, the new Medicaid Managed care Rule, and the collaboration of Managed Care Organizations and Accountable Care Organizations to reduce health care spending and improve efficiency of care.

Enthoven, A.C. (1993). Why Managed Care Has Failed To Contain Health Costs. Health Affairs, 12, no.3 (1993):27-43 doi: 10.1377/hlthaff.12.3.27. Retrieved from h

To own a physician practice and deal with health insurance companies where prices for healthcare services are dramatically reduced that reflect what Medicare allows, could be problematic and promote massive losses. If the practice has privately paying patients, this may balance those losses. This day and age if the physician decides to expand the practice to include one day per week for uninsured patients to receive care, his practice has demonstrated added clinical, strategic, and operational value (Pointer, Williams, Isaacs, Knickman, & Barr, 2007, p. 289).

The rising cost of medical care in America during the 1960s necessitated an intervention to keep costs low without compromising quality of health care. Health Maintenance Organisations (HMOs) would lead the way in heralding in a new era in health care financing and remodelling the economics of health from a non-profit making industry to a highly profitable entity powered by the insurance sector. Enactment of the Health Maintenance Act in 1973 would be a milestone in the history of managed care. Institutions providing managed care plans would come up with various packages to suit both their consumers and health care providers, all the while maintaining their profit margins.