Different Types Of Managed Care

Pay-for-performance payment model – healthcare payment systems that offer financial rewards to providers who achieve, improve or excel their performance on specified quality of care and cost measures (HealthCare Incentives Improvement Institute, N.D.)

Insurance can be purchased through private companies or the Marketplace. The Marketplace provides “income-based premium subsidies for low and middle income people.”

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

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.

Health care insurance in the U.S. is extremely competitive and not always fair. Recently in 2012, The Affordable Care Act passed by Barack Obama set new regulations regarding insurance. According to this Act, employers of 50+ employees must offer health insurance, public health insurance such as Medicare and Medicaid was made affordable for those that qualify, it is illegal for anyone to be denied insurance due to pre-existing conditions, and everyone must have health insurance or they will endure tax penalties. For Medicare and Medicaid, each state has different qualifications regarding eligibility. Private health insurance is not mandatory, but many of those that can afford it prefer it because it will cover more than any government insurance. Private health insurance also offers family plans along with single plans(varying from company to company), which will definitely attract middle to high income families. Health insurance is an absolute essential in the U.S. as it is up to the citizen to obtain one that works for them.

In the United States, access to health care is largely determined by who has financing to receive insurance (Shi & Singh, 2013, p. 197) Financing for health care comes from many different entities. For most Americans who have health insurance through their employment, the employers pay a part of the insurance premium and employees pay the rest (Shi & Singh, 2013, p.

Another type of managed care program that was introduced is the Preferred Provider Organization (PPO). A PPO is comprised of a group of physicians, hospitals and other medical service providers who contract with employers, insurance companies or other plan sponsors. The PPO offers discounted pricing to these contracted organizations due to the high volume of business received. PPO’s typically have up-front cost sharing in the form of deductibles and/or co-insurance, which vary depending upon the actual plan chosen.

Health insurance in the United States is not a single nationwide system and is much more diverse in terms of production methods (Ridic, Gleason & Ridic, 2012). Health insurance is either purchased privately or provided to some public groups from the government, mainly Medicare and Medicaid (Ridic, Gleason & Ridic, 2012). Medicare is a nationally run program for aged and disabled individuals (Ridic, Gleason & Ridic, 2012). Medicaid provides coverage economically disadvantaged groups (Ridic, Gleason & Ridic, 2012). The Affordable Care Act of 2012, established a shared responsibility between the government, employers and individuals ensuring all Americans have access to affordable health insurance (The Commonwealth Fund, 2016). For private

The Medicaid program is jointly financed by the federal government and states. The federal government pays states for a specific proportion of program expenses, called the Federal Medical Assistance Percentage (FMAP). FMAP varies by state based upon criteria such as per capita income. There are no intermediary like Medicare’s HMO and PPO, so payments are made directly to providers. Medicaid covers health insurance up to 400% of Federal Poverty Line for those who are under age 65 and poor and/or disabled through income and excise taxes. Elderly over age 65 who are poor are dual eligible for Medicare and Medicaid. There is an employer-based insurance (EBI) and cost share is between employees and employers.

For Americans, health care coverage depends primarily on whether health insurance is provided by their employer or through two major public programs, Medicaid for the poor and Medicare for the elderly.

Another reimbursement is the Pay-for-performance model where the providers are only paid when they are able to achieve a specific goal. “Insurers pay providers an “extra” amount if certain standards, usually related to the quality of care, are met”(Gapenski, 2013, p.69) The

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

Understanding the classification of healthcare services in terms of acute and long term care enable us to plan for services, to describe institutions, and to allocate funding and reimbursement. In the United States, healthcare services provided by health care providers (such as doctors and hospitals) are paid for by the following including, private insurance, Government insurance programs, people themselves (personal, out-of-pocket funds). Additionally, the government directly provides some health care in government hospitals and clinics staffed by government employees. Examples are the Veteran’s Health Administration and the Indian Health Service.

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.

Thanks for your informative post, I agree, pay for performance is a reimbursement method aimed at improving the experiences of patients at various health institutions. This method as you mentioned is becoming popular among health care policymakers and health care insurers. it is a method based on incentive paid by health care insurers to providers to encourage the overall improvement of providers’ healthcare services to their patients . The pay for performance is considering a method of reimbursement that has shifted much of the financial risks to the providers of health care. The shift in risks to providers could be a double-edged sword. For one, the method can be credited for allowing physicians accountability for costs containment and wellbeing of their patients to be emphasized within the health arena. On the other hand, P4P could result in physicians enrolling patients with less complicated health problems in the practices, or it could lead to physicians avoiding healthcare facilities in poorer neighborhoods with many chronic ill patients. That said, researchers do not concur that the pay for