How Managed Care Is A System

PPO- This plan contracts with physicians and facilities to perform services and a specified rate. Its to ensure that PPO members are charged less than nonmembers

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 HMO’s stress wellness and preventive care, therefore its focus is more on health maintenance rather than just the treatment itself. Because of this, HMO’s offer much richer benefits than the traditional plans. HMO’s have little to no upfront costs in an effort to encourage maintenance, while comprehensive and major medical plans have up-front cost sharing so as to discourage over utilization.

The U.S. health care system is a scrutinized issue that affects everyone: young, old, rich, and poor. The health care system is comprised of three major components. Since 1973, most Americans have turned to managed-care programs, known as HMOs. The second type of health care offered to Americans is Medicare, health care for the elderly. The third type of health care is Medicaid, a health care program for the poor.

rising health care costs. Managed care can be defined a system of delivering health services in

The book discuss about three major types of managed care organization: health maintenance organizations (HMO), preferred provider organizations(PPO), and point of service plans(POS). Managed care has been around for minute. This organization has been around since 1930s. The three managed care organizations are require an agreement between the insurer and a network of health care providers. Policy holders are encouraged to use the providers in the network by the fact a percentage will pay the cost of care if received outside the network.

The relationship of an HMO and its physician member is to help provide a wider range health care for its patients and a wide area of services available for its physician members. A patient must choose a primary care physician from a list of providers. The relationship with the physician provided from the HMO is in a contract that is to deliver services to their patients for a fee. There can also be a group plan which is a HMOs contract with a group of physicians to deliver services. The HMO organization compared to PPOs, a PPO is a variation of an HMO, and it features traditional insurance and managed care.

A health maintenance organization (HMO) is a type of managed healthcare system. HMOs, and their close cousins, preferred provider organizations (PPOs), share the goal of reducing healthcare costs by focusing on preventative care and implementing utilization management controls.

Under the plans listed above, the managed care plans (HMO, PPO, and POS) offer the best methods of containing costs while encouraging accountability and patient outcomes. Each plan has limitations because of the structure of the program. For example, HMOs can manage costs and encourage accountability, but may restrict patient outcomes because of the organizational acceptable care plans to treat certain diseases. HMOs manage care by utilizing general care which may or may not treat the specific disease that the patient is suffering from and limits the types of acceptable pharmacological treatment for the disease. This can be frustrating for both the provider and the patient because of the limitations placed by the

“…Paul Ellwood (along with the Nixon administration), a physician specializing in rehabilitation medicine, who through his Minnesota think tank InterStudy promoted the term HMO and saw it as the building block for an entirely different approach to health care reform” (Oliver, 2004). According to the National Library of Medicine, “managed care plans are health insurance plans that contract with health care providers and medical facilities to provide care for members at reduced costs” (www.nlm.nih.org). The categories of plans include Health Maintenance Organization (HMO), Preferred Provider Organizations (PPO), and Point of Service (POS). According to the American Heart Association the goals of managed health care ensure that “providers deliver high-quality care in an environment that manages or controls costs, the care delivered is medically necessary and appropriate for the patient’s condition, care is rendered by the most appropriate provider, and care is rendered in the most appropriate , least restrictive setting” (www.americanheart.org). Due to the customization ability of managed care plans individuals control their respective health coverage and allow cost reduction cooperation between health organizations and

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 managed care plan coordinates the financing and delivery of health care services of its members in order to provide the highest quality services at the lowest possible cost. These providers form the plan network. The network have rules that determine the amount of coverage your plan will pay. Restrictive plan cost less than flexible ones. HMOs pay provider within their network. Most patient's care is provided y a practitioner. PPOs pay provider within their network, but also pay provider outside their network. POS plans allow the insured to choose between an HMO or a PPO each time care is required (MediLexicon International Ltd, 2015).

Managed care is a type of system that was formed to help control the costs and quality to health care services; this will give access to services to specific groups of covered patients. The system was created to help the patients (customers) to receive services without having the full financial burden (University of Washington, 1998). The managed care services’ goal is to be able to help individuals and their families by providing health care services that is affordable. This type of managed care will help employees or individuals by requiring a set fee to be paid to the physician for visits, a co-pay and monthly premium to be paid to the insurance company. This will

PPOs - preferred provider organizations, usually hospitals that offer reduced rates based on contractual arrangement with the organization

Managed Care – This is a type of health care where patients sign up in a plan to visit particular doctors and hospitals whereby the cost of care and treatment is monitored by a managed care organization. (Free Dictionary, 2012). “A health care system with administrative control over primary health care services in a medical group practice.” (Free Dictionary, 2012).