Code Of Ethics In Managed Care

One of the major cornerstones of health care services is the physician-patient relationship because it involves the data collection medium, development of diagnoses and plans, achievement of compliance, patient activation, healing, and provision of support (Goold & Lipkin, 1999, p.26). In managed care organizations, the significance of physician-patient relationship is also based on market savvy i.e. determination of individuals' decisions to join and stay with a particular organization. The importance of this relationship is evident in the fact that it has

As we all know Managed Care Organizations (MCOs) have one major goal, and that is to save money. Whether it is by reducing care, incentivizing doctor s or advertising, they are pursuing their goal. In fact, we all know that back in the 70s the rise of healthcare cost pushed this initiative, and that although it has been criticized over the years, it has proven to some extent that it does reduce cost, to the point that Medicaid and Medicare have adopted their model. However, despite all the efforts, healthcare costs continued to rise, and skepticism arose. In fact, it wasn’t long until people were saying that managed care had failed. Furthermore, a new tool was developed

In addition, the article highlighted the issue of litigation and policy context under the Employee Retirement Income Security Act’s (ERISA’s) preemption provision. It stated that “when a law or legal action involves the administration of plan benefits, such as a state law mandating certain benefits or a patient’s challenge to the denial of a plan benefit, ERISA preemption is triggered” (Jacobson, 1999). Therefore, the states block the litigation against the managed care organizations. Lastly, the courts and public policy have been a challenge of the implementation of cost containment initiatives. Some prominent commentators have been arguing for years that health care delivery should be guided by market principles as determined through contractual

The training will includes healthcare codes of ethics for managed care and five ways to improve ethics in the managed care organization.

This article scrutinized the amount of managed care contracts and how they correlated to the quantity of patient care hours a physician reports. Also surveyed was the percentage of hours reported by a physician for caring patients outside the practice. An alternative for administrative time was the observations of having sufficient patient time, career gratification, and revenue generated from the practice.

The Managed Care System was introduced to control the cost for health services provided to individuals. Managed care controlled who the consumer would seek health services from, as well as the cost of the service provided. MCO’s became deep-seated when President Nixon signed the Health Maintenance Organization (HMO) Act in 1973. The first type of managed care used were HMO’s and the purpose was to keep healthcare costs within limits. Physicians of course were against the Act. This would now control the fees that the physician would charge for the services they provide to the individual. As Managed Care evolved and increased in the amount of managed care plans that became available over the years. Physicians preferred guaranteed income as oppose

Health maintenance organization’s (HMOs) use of the primary care physician (PCP) as the “gatekeeper” initially had MCOs view restrictions as a negative approach to patients’ choices. However, some necessary steps have started to be implemented which reduce unnecessary utilization by enforcing some restrictions.

Change is inevitable when it is a faltering system; such as health care and insurance, which means in the health care industry there is nothing constant in the contemporary managed care systems. When speaking of managed health care, some find it to be an institution set forth as a response to the consistently rising health care costs, that some viewed as detrimental to the United States economy as a whole. Others viewed managed care as a documented response to health care quality problems that have long been ignored. That the problems managed health care would specifically help rectify patterns of over and underuse, misuse, and any geographic variation in the medical services provided to citizens (Kongstvedt, 2001). Both of these ideals had a hand in the wide spread adoption of managed health care in the United States, they do not define the foundational and personal changes that needed to occur in order to accommodate such a large change. However, following the introduction of the health maintenance organizations or HMO’s there has been an over flow of managed care programs and products being created in the United States.

Health care organizations are complex entities whose theory and structure have evolved and transitioned over time. In the late 1980s and early 1990s health care experienced a paradigm shift as managed care organizations guided health care practices by managing the care between patients and physicians in order to drive down health care costs. This transition has created controversy and discontent as physicians, patients and payers balance what is required to ensure quality care. The movie Damaged Care introduced the organizational structure of the managed care organizations, the hierarchy of care within the organization, the power struggle within those organizations and the impact it has on the clinical decision making and ultimately the patient. This paper will analyze the organizational theory that drives the managed health care, the roles and motivators of all parties involved and the effects organizational actions have on the consumers’ care.

Patients should prepare to have a higher health insurance cost or a higher “out of pocket” costs so they don’t freak out when they get their bill. Patients need to know and understand their health insurance policy, for example brand and generic drug costs, co-pay for doctor visits and etc. They should be assertive in dealing with their own insurers, providers, and case managers. I agree that many of the changes that have led to a managed care system are rooted deeply with the economic realities. Furthermore, I agree that while hospital closings and mergers create many issues and concerns, both the declining number of beds and the declining number of admissions is related to a decline in the number of in-patient

Managed care integrates the delivery of health care and financing of health care. In managed care, insurance companies controls the cost, quality, and access of medical care to beneficiaries by limiting the reimbursement levels paid to providers,, by reducing utilization, or both (Beik, 2014, p. 116). There are different types of managed care. Some of the most common types of managed care are Preferred Provider Organization (PPO) and Health Maintenance Organizations. Managed care programs uses different interventions such as economic incentives for doctors and patients, increased cost sharing, controls on inpatient admission and length of stays, and so forth (Deom, Agoritsas, Bovier, & Perneger, 2010, p. 1). On the other hand, managed care tools such as gate keeping, health care networks, second opinion requirement, and pre approval requirement for expensive treatments or hospitalization has changed healthcare delivery on both the macro and micro levels. On the micro level, it greatly impacts the quality of care, cost, autonomy, and relations with patients. According to the research study, managed care greatly affects physicians. It reduces career satisfaction through its impact on doctors’ autonomy and the pressure caused by managed care may affect the doctor’s ability to provide high quality of medical care. (Deom, Agoritsas, Bovier, & Perneger, 2010, p. 7). Like for example, managed care contracting has a positive and negative impact on physicians and patients. The

Managed care has influenced and changed the ways in which healthcare providers make medical decisions. With the introduction of managed care, the control of the decision making has shifted from the physicians to the managed care organizations (Fottler & Malvey, 2004). Managed care has been accused of focusing more on costs and profits than on patient care. After a decade of cost management and distribution of cost savings to investors, administrators and employers will yield to legal, employee, patient, and provider pressure for access. In fact, financial cuts influence providers' decision, for example, to cut staff and to replace expensive and experienced staff with cheap inexperienced staff. Physician loss of freedom to make medical decisions, and to implement those decisions, breeches the doctor-patient relationship. This theft of autonomy, but persistent moral and legal burden of responsibility for patient care has demoralized physicians.

The Iron triangle for healthcare consists of cost, quality, and access; these three characteristics when balanced create great healthcare. Managed Care Organizations combine the three to offer consumers with care that is appropriate for their individual needs. Our book describes managed care organizations as “the cost management of healthcare services by controlling who the consumer sees and how much the service cost” (Basics of the U.S Healthcare System, Niles). Taking a look at the history prior to the Health Maintenance Organization Act of 1973 (HMO ACT of 1973) the implementation has been significant in balancing cost, and quality control. Before this Act was signed in to law by President Nixon healthcare costs were determined by fee for service. A fee for service or indemnity plan is a plan that allows the provider to determine the cost of service, this fee for service plan caused for healthcare costs to increase rapidly. An example of this would be going to the doctor with neck pain, being told to stretch then receiving a bill for 25,000 dollars. As could be understood the cost of healthcare had became a problem.

It is key to communicate during this presentation that, “serious challenges are associated with attempting to describe the types of organizations in a field as dynamic as managed care. The health care system in the United States has been continually evolving and change is the only constant. Nevertheless, distinctions remain between different managed care organizations (MCOs), though many of those distinctions are rooted in the historic classifications that separated different forms of managed care, particularly during its time of rapid growth. Despite the continual blurring of types of health care plans, it is useful to understand the different types of organization even though the pure form may only rarely be observed. It also is worth noting that research done

This act is immoral, and it is important that it be reported to the responsible authorities (Shahri, Hosseini, Phalp, Taylor, & Ali, 2014). In such a case, I would apply my code of ethics of Trust, to tell the truth to the relevant authorities regardless of how the patient may feel or think about me. However, due to the caring part, I may try to help the patient receive the treatment that she needs since it is a serious matter. According to Tarzian, Social, & ASBH Clinical Ethics Consultation Affairs Committee. (2015), any health concern should be addressed first before any additional claims of ethical behaviors and practices are examined.