Improving The Health Care System

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.

External and internal influences are relevant in health care. These influences continue to affect the total operations of a health care facility. I will summarize the insights I have gained into the external influences of the new health care reform policy and quality initiatives. The recent health care reform legislation was passed in the house and senate this year. The senior vice president, that I have interviewed, states that health care reform is an “unknown” for organizations. In addition, I will research the quality improvement initiatives and how these external influences include implications for organizations and health care administrators.

Over the course of our countries history, the delivery of our health care system has tried to meet the needs of our growing and changing population. However, we somehow seem to fall short in delivering our goals of providing quality, affordable and accessible healthcare to our citizens. The history of our delivery system will show we continuously changed the delivery of our system however never mange to control cost. If we can come up with efficient ways to cut cost, the delivery of quality care will follow.

Triple Aim, as defined by the Institute for Healthcare Improvement, consists of improving patient experience of care, improving health populations, and reducing per capita health care costs simultaneously (IHI, 2009). Triple Aim is not focused on patient satisfaction or on reducing the growth of healthcare; rather it is based on the six Institute of Medicine (IOM) dimensions (safe, effective, patient-centered, timely, efficient, and equitable), reducing per capita healthcare costs, and improving health populations (Relman, 2001). Key to the Triple Aim model is understanding each element works in tandem with each other and sacrificing population health at the expense of reducing per capita expense, for example, does not comply with the Triple Aim

Triple Aim, as defined by the Institute for Healthcare Improvement, consists of improving patient experience of care, improving health populations, and reducing per capita health care costs simultaneously (IHI, 2009). Triple Aim is not focused on patient satisfaction or on reducing the growth of healthcare; rather it is based on the six Institute of Medicine (IOM) dimensions (safe, effective, patient-centered, timely, efficient, and equitable), reducing per capita healthcare costs, and improving health populations (Relman, 2001). Key to the Triple Aim model is understanding each element works in tandem with each other and sacrificing population health at the expense of reducing per capita expense, for example, does not comply with the Triple

The Triple Aim provides guidance for the creation of strategies to address the suitable delivery of health care services such as, improving patient care coordination and chronic disease management, preventative health, and eliminate the misuse of healthcare services. The fundamental idea with initiating the triple aim is to simultaneously work at all three goals to achieve better patient health and health care systems. According to Bucher & O 'Day (2014), Triple Aim is the answer to optimize health system performance and patient outcomes. An analysis of Triple Aim reveals several difficulties with implementation, the importance of population health, attempts to “bend the cost curve”,

There has been discussion to have universal healthcare system similar to Medicare as a method to have a centralized monitoring system of cost. There have also been other systems tried beginning with HMOs in the 1970s in an effort to streamline access to necessary healthcare services by employing a gatekeeper to their access at the primary care levels. With patient dissatisfaction, PPOs were tried which circumvent the necessity of referrals (Hacker, 1998). Either of these models had substantial effect on healthcare outcomes while the cost of healthcare continued to skyrocket. The US spends more than any other country on healthcare but outcomes are not better (Blackstone, 2016). In 2010, under President Obama’s leadership, Affordable Care Act was passed and one of the promising features is the formation of accountable care

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

Health care spending grew 3.7 percent in 2012 and the traditional way medicine was practiced had to change (Edlin, Goldman & Leive, 2014). The Affordable Care Act and Population Health was designed based on the concept of “The Triple Aim” to foster change in patient care by providing better care for individuals, better health for populations and decrease the cost of health through improved care (Perez, 2014). As a result, population management has moved to the front by linking services, reducing hospital admission, risk stratification, pursing preventive medicine, ensuring medication review and lowering health care cost. Several organizations have follow in the pursuit of population management by forming Accountable Care Organizations

To guarantee that its members receive appropriate, high level quality care in a cost-effective manner, each managed care organization (MCO) tailors its networks according to the characteristics of the providers, consumers, and competitors in a specific market. Other considerations for creating the network are the managed care organization's own goals for quality, accessibility, cost savings, and member satisfaction. Strategic planning for networks is a continuing process. In addition to an initial evaluation of its markets and goals, the managed care organization must periodically reevaluate its target markets and objectives. After reviewing the markets, then the organization must

Managed care has become so popular because of its capabilities to deliver health care at

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

As stated above, the Triple Aim framework was developed by the IHI with the aim of providing quality care, improving patient health, and containing costs for healthcare services. The IHI pursued developing this model to improve healthcare outcomes within the United States to gain better utilization of resources for medical and social services (IHI, 2016a). By 2020, estimates suggest that the U.S. health care system will grow to nearly 20% of the gross domestic product of the country (IHI, 2016). In order to contain costs and increase the quality of care, a systematic change must be developed throughout the country .

The current health care sector is too costly and too fragmented with a lot of variation in care even with established evidence based guidelines. Providers lack the tools, support and information they need to offer the coordinated health management that can reduce cost and improve outcomes. Primary Care Physicians are constrained in their abilities to perform any proactive care that involves avoiding Hospital or ER visits, and influencing healthy lifestyles.

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.