Health Care Criteria Throughout the World

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

United States is the largest and most diverse society on the globe. It spends almost 2 trillion dollars every year on health care, which is one in every seven dollars in the economy. U.S is one of the very few nations where all its citizens do not have medical coverage. Although it spends heavily on per capita on health care, and it has the most advanced medical technology system in the world, still it is not the healthiest nation on earth. The system performs so poorly that it leaves 50 million without health coverage and millions more inadequately covered (Garson, 2010).

In The Healing of America: A Global Quest for Better, Cheaper, and Fairer Health Care (2009), the author of the book, T.R. Reid travels to industrialized democracies to discuss the different methods of health care delivery system used in these developed countries and compare them to the health care system of the United States. According to T.R. Reid (2009), “the thesis of this book is that we can find cost-effective ways to cover every American by borrowing ideas from foreign models of health care” (Reid, 2009, p. 11). This thesis illustrates that the American health care system can manage health care costs effectively and provide care to all by using some of the successful health care delivery models of foreign nations. The purpose of this book analysis is to discuss the four different health care models presented in this book and provide my prioritization or ranking of these models. This analysis also aims to investigate a case known as the Nikki White case described in this book and discuss the lessons learned from it. Furthermore, this analysis is going to provide my remarks on the, “An Apple a Day” comment relative to the Public Health Model. Lastly, in this book analysis, I will share my conclusion on the basic premise of the book along with my take away messages that I will remember into my future as a Public Health professional.

Critics believe that the present functioning of managed-care is degenerative to health care. Managed-care firms control costs by requiring patients to use a “network” of approved doctors and hospitals, and by reviewing the actions of doctors. Patients have to pay more to visit a doctor who does not participate in the “network.” Managed-care firms second-guess doctors, considering only the costs. Patients are often prevented from visiting specialists to reduce costs. A managed-care company might insist that its doctors prescribe inexpensive generic drugs instead of commercial products. Many patients must, also, receive the insurer’s approval before undergoing treatments or operations. HMOs have been criticized for refusing to pay when a patient goes

When the general public is not satisfied with or lacks understanding of their health care system, it is easy to think another countries health care system may be better off. With this said, the best place to start is to define the health care system in the U.S. and in Canada. Canadian’s have more of a right to health care as they are automatically covered from birth until they die. This coverage is for both health care services and prescription medication coverage. The Canadian government is the controlling power behind their health care system with this current system beginning in 1984. Even though the health care system is government controlled, it is not however, government owned, “Doctors and facilities are privately operated and paid for through taxes”, (Mangas, 2013). The U.S. on the other hand, “has both private insurers and a public system”, (By Admin,

managed care grew more in the last years, bringing about new types of managed care plans through competing MCOs. To make their plans more attractive, organizations used payment variations. For instance, instead of capitation, PPOs used discounted fees payment. There were ones that offered enrollees choices between affiliated providers and non-affiliated providers. MCOs also adopted various methods to control health care costs by actively monitoring utilization (Shi, Singh, 2017). Additionally, private health insurance, as well as high deductible health plans, can be offered as managed care plans nowadays. Also, available to Medicare and Medicaid recipients is the option to enroll in a managed care plan or continuing to stay with the traditional fee-for service program. Now for specific services HMOs incorporates capitation and fee-for-service reimbursement, in their payment schemes.

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

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

The plan only pays a portion of the services and has deductibles that must be met by the individual based on income (Nowicki, 2015). There are different plans under Medicare that reimburse for different healthcare services.

This week's reading in regards to patients care was very educational in learning the struggles of millions of Americans in need of healthcare. The shift from fee-for-service to manage care such as HMO has made it difficult for patients to get the proper health care. Strategies used by HMO included restricting patients choices of physicians; controlling their access to care, limiting the treatments their physicians prescribed; limiting the doctors ability to refer them to specialists and evenually damaging the patient's trust in their doctors.

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.

Health care in the United States remains different then compared to other nations. The United States takes a different direction by making a medical welfare system for the poor and the elderly and leaving the rest of the

The mandatory benefits that Medicaid insurance is federally required to cover include: Inpatient and outpatient hospital services, early and periodic screening, diagnostic and treatment services, nursing facility, home health and physician services, rural health clinic services, laboratorys and x-rays, family planning, nurse midwife, and freestanding birth center services, certified pediatric and family nurse practitioner services, and medical transportation (Goldman, 2005). Along with the mandatory requirements, there is also a list of optional benefits that many states are using to expand Medicaid. These optional benefits include: prescription drugs, physical and occupational therapy, speech, hearing and language disorders, respiratory care, podiatry and optometry, dental, prosthetics and eyeglasses, chiropractic, personal care, hospice and private nursing services (Goldman, 2005). States also have the option to charge premiums and establish out-of-pocket spending for Medicaid enrollees (CMCS, n.d.) These out of pocket costs can include co-payments and deductibles. However, certain groups including children and pregnant women, are exempt from most out of pocket costs. States can also charge a higher co-pay when Medicaid enrolled individuals visit a hospital’s emergency room for a non-emergency service (CMCS,

There are a variety of health care systems around the world, which differ in accessibility, quality, price, and receptiveness to change. While some developing countries offer no protection to its citizens, some countries that dictate the entirety of quality of care of hospitals, and some countries that provide equal access to good, quality, care to its citizens. While there are no perfect systems of healthcare, there are always ways to improve upon the system of healthcare in our countries. Particularly, the US and UK systems of healthcare differ based on how they allocate resources, the incentives for their workers, and overall quality of care. Based on these factors, the US overall has a better healthcare system than the UK, despite the UK having universal healthcare.

The term Health Maintenance Organization (HMO) was developed in 1970 as part of the Nixon Administration to promote the growth of prepaid plans as a way to improve the nation’s health system. The Health Maintenance Organization has an appearance on the outside of being very appealing to those with little money to spend on insurance because it has a very low premium cost, but the truth be known that sometimes cheaper is not always better. In this paper I will discuss how HMO’s have influenced current healthcare systems.