How Healthcare Has Changed and Where it Is Going

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 is continuously changing. In the past several years there has been a large shift in the focus in hospitals. The focus has changed from the staff to patients, patient satisfaction, and cutting costs in order to budget more tightly (Tarrant & Sabo, 2010). Because of this, along with the extreme increase in a number of patients seen and the acuity of the patients, nurses are being overworked. As a result, role conflict and ambiguity is becoming an issue. The purpose of this paper is to discuss role conflict and ambiguity, its significance, and its application to nursing.

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

This paper examines the benefits and issues with managed care. The benefits include patients receiving preventative care, lower premiums, lower costs of prescriptions, fewer, unnecessary procedures, and less paper work. Some issues with managed care include limitation on doctors that patients can choose from, restricted coverage, the possibility of under treatment, and compromised privacy. Managed care effects nursing by causing significantly few jobs for registered nurses, more opportunities in non-acute health care settings, and more use of advanced practice nursing.

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

America's revenue model for its healthcare system is a disaster in waiting. A visit to the doctor results in an insured customer paying only a meagre portion of the bill. This is known as co-pay. The bulk of the bill, 88% percent to put into perspective, is being paid by public and private

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.

At one point, managed care was the viewed as a resourceful tool in efforts to help assist employee, physicians and hospitals with quality health care, while controlling the cost of medical care in the United States. Over the past 30 years, managed care has been in the limelight of health insurance, as a dictator of how it will pay for medical bills. There have been many factors playing a role with managed care over the years. For example, due to the slim selection of options that are available with physicians in rural areas, and limited physicians to choose from, does this compromise the quality of care of each member or does this cut off services for members

Looking back at our former healthcare system, we see that it was far from flawless, some say it is due to the government, while others claim the health insurance and the healthcare system in general is to blame. So it 's no wonder that the healthcare system is constantly fluctuating. These fluctuations have let us to a system that was very flawed and in dire need of rectification. Furthermore, the health insurance market wasn’t readily accessible to the middle and lower class, due to high costs, bizarre prerequisites, and complicated terminology.

Healthcare expenditures have more than doubled since 1965. Americans spend over a trillion dollars a year on health care. (2). As of 1996, 110 million Americans were enrolled in HMO's. More than three-fourths of all individuals in HMO's are covered by job-based insurance. More than 13 million Medicaid recipients have been put into managed care plans. Managed care and HMO's have been the subject of many negative stories in the press and are constantly being charged with endangering the health and lives of their enrollees. As a result, congressional hearing, state, and federal regulation, and action by the

The year I was born brought a great change in medical history, and no it wasn’t simply because I was born. In 1986 the Emergency Medical Treatment and Active Labor Act was created. This is an act that the United States Congress passed as a part of the Consolidated Omnibus Budget Reconciliation Act (COBRA). It is stated that “It requires hospitals that accept payments from Medicare to provide emergency health care treatment to anyone needing it regardless of citizenship, legal status, or ability to pay. There are no reimbursement provisions. Participating hospitals may not transfer or discharge patients needing emergency treatment

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

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.

The health care industry exist to provide preventative measures, diagnose health conditions, repair, and provide services to improve the quality of life. The cost of health care continues to rise each year. Health care fraud is a factor that continues to plague the health care industry. The affect health care fraud has on hospitals, is the increasing cost of medical services. The following research will examine and evaluate how organizational structure and governance, culture and the lack of focus on social responsibility affects on health care fraud. The following research will also include recommendations for prevention of health care fraud, recommendations for