Essay On Managed Care

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

Each state has their own policies for Medicaid eligibility, services and payments. Medicaid plans have three eligibility groups such as categorically needy, medically needy and special groups. Children's Health Insurance Program (CHIP) is a program that offers health insurance coverage for uninsured children under Medicaid. If Medicaid does not cover a service, the patient may be billed if the following conditions have been met such as the physician informed the patient before the service was performed that the procedure was not covered by Medicaid and if the patient has signed an Advance beneficiary Notice form. However, there are also conditions where the patient cannot be billed if necessary preauthorization was not obtained or service

In this country there are numerous concerns about health care economics. Several factors contribute to the increase of health care costs. One area of concern is the impact of managed care on health care finances. Managed care has been around since the early 1970s. The definition of managed care is a set of contractual and management methods implemented to manage the financing and delivery of health care services. Initial implementation of managed care was for health care cost saving (Getzen & Moore, 2007, p. 203, para. 1). Though Managed care initially addressed several health care finance issues, there are still problems with the current

To decide on whether or not an issue is considered ethical or moral we need the hard cold facts. Facts expose or explain what is to be decided upon—not what the outcome should be. Decisions regarding health care and mental health issues represent a major portion of ethical and moral choices. As individuals we are not always able to understand the justice, or fairness, behind the decisions supposedly based on hard cold facts.

In a health maintenance organization, a contract is made between enrollees and a panel of providers. The enrollees use the method of capitation for payment, meaning they pay a predetermined fixed fee monthly for a period of one to three years regardless of how many times they use their medical service or of how much it costs each time (Chitty & Black, 2007). In a preferred provider organization the a contract is made between the client and a group of independent doctors that team with hospitals to provide cheaper health services for their patients (Chitty & Black, 2007). They are able to provide some of the lowest fees because they have such high volumes of patients to make up for the discounted price (Huntington, Glossary For Managed Care, 1997).

The Patient Protection and Affordable Care Act, more commonly known as Obamacare, was authoritatively marked into law on March 23, 2010. It was created to make healthcare lower-priced and effectively available to a more extensive scope of Americans. Under the law, individuals in the United States who do not meet all requirements for an exemption are obligated to acquire a minimum amount of healthcare coverage.

What is managed care? According to the Oxford English Dictionary, managed care is “a system of health care in which patients agree to visit only certain doctors and hospitals, and in which the cost of treatment is monitored by a managing company.” Managed care is a variety of techniques designed to essentially reduce the cost of providing health benefits and advance the quality of care. In the United States alone, there are various managed care programs, that span from less restrictive to more restrictive. As recently stated in the National Institutes of Health, the future of managed care is uncertain. It is enthralling to note that in spite of the advances in the health care systems, such as our hospital’s ability to provide patients

In an attempt to understand the impact of managed care in the U.S, I look at the most commonly expressed complaints against the organization. In a survey of consumers, 60% said that managed care had not made a difference in health care cost or had actually been the cause of the increase of health care cost. Managed care has had an impact on slowing the rates of growth in the costs of two major health care producers: hospitals and physicians. Little evidence has suggested that the current reimbursement are inadequate to the care provided. The quality of care is a highly debated issue. Physicians are concerned that the quality of care in managed care organizations may reflect the loss of professional autonomy through pre-authorization procedures.

Managed care was born out of necessity. It involves plans, members, providers, and payments intertwined, one not working without the other. With managed care came rising health care costs. Utilization management and quality initiatives were introduced to help control these costs. Medicare and Medicaid were also helpful in setting standards of care which reimbursement is based on as well as providing access to health care for more people. Health care costs continue to rise but with passage of the Patient Protection and Affordable Care Act (ACA) the goal is more people will have access to affordable, quality health insurance while reducing the growth in our healthcare spending.

Managed care has been adopted into the government funded care organizations. Medicare managed care plans provide all coverage themselves, including basic Medicare coverage. Managed care plans cover above and beyond the basic benefits of Medicare, the size of premiums and copayments, and the decisions about paying for treatment are controlled by the managed care plan. The basic premise of managed care is that the member/patient agrees to receive care from only a specific doctors and hospitals, in exchange for reduced healthcare costs. Medicare, like other insurance companies offer plans that give Medicare beneficiaries more choices in coverage, like HMO or PPO. Managed care has been used since the mid 1990’s in order to provide healthcare to beneficiaries with serious or life long illnesses. Today, managed care has become a way for states to provide quality care to both Medicaid and Medicare patients.

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

Managed care is the most dominant healthcare delivery system in the United States and available to most Americans. Employers and government are the primary financiers of managed care. The managed care sector includes approximately

The both of publications illustrate the relationship and collaboration between public health and managed care, advantages and disadvantages of managed care. If I were the editor of this journal I would select article two for publication for several reasons. Article 2 states a complete and obvious perspective about managed care. It provided a completely definition of managed care and its functions. In addition, it illustrates the convincing example for cooperation between public health and managed care. As mentioned in the article two that the modern public health furnishes many services such as immunization, protection from environmental hazards and so on. Those services cannot be provided without managed care or the health care delivery system.

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.

According to Gapenski and Pink (2015), “Under capitation, providers receive a fixed fee for each patient enrolled in the capitated plan” (p. 87). As stated above, capitation creates a significant incentive for providers to control the cost of delivering health services, by being paid a fixed amount for each patient enrolled, providers are motivated to control the number of services provided. On the other hand, under capitation, if providers do not control the cost of delivering health services, the cost per member enrolled will exceed the fixed payment. In addition, since the control of the net profit obtained