Managed Care: A Literature Review

Health care cost has risen dramatically in the last decade. Health care plans have been forced to look at the quality of health care given by the providers so they can implement certain strategies to help reduce heath care costs. Managed Care describes a group of strategies that is looking to reducing the costs of health care for health insurance companies. (Kongstvedt 2007)

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.

One of this health care’s programs objective is to limit the number of uninsured (Shi & Singh, 2015). This controversial healthcare plan incorporates a privately funded insurance which is paid for through employment and solely by the patient and a publicly funded insurance by the government. Medicare is provided for senior citizens 65 and older, and Medicaid is provided for low income citizens. The federal government and state government both partake in the funding of Medicaid. Although insurance is provided to the low income through Medicaid, the United States continues to suffer from cost escalation spending 17.1 percent of GDP on healthcare in 2013, a 50 percent more than the second nation (Commonwealth, n.d.) The high cost and limited coverage continues to spark up the conversation for a

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

Medicaid is one of the most widely acknowledged sources of health insurance coverage in the United States, benefiting over 48 million low-income children and parents (Hansen, 2012). It also supports those over the age of 65 who may also receive Medicaid. By providing essential health insurance protection, Medicaid supports the growing un- and under- insured population. This federal program for the financially needy is administered at the state level. Coverage varies and each state creates its own rules, typically offering support through county social services, welfare, or other department of human services offices (Goodman, 1991).

Managed care in simple can be defined as an organized approach to delivering healthcare services in an efficient way to enrolled members by negotiation of prices and payments with the providers. Managed care is one of the dominant influence that as transformed the healthcare delivery system in the United States since the 1990s. Managed care has two different contexts to it.

Throughout the early 1980’s and 1990’s the Federal Medicaid program was challenged by rapidly rising Medicaid program costs and an increasing number of uninsured population. One of the primary reasons for the overall increase in healthcare costs is the

As previously illustrated, there are both advantages and disadvantages of Medicaid. However, being a beneficiary of Medicaid increases access to health care. As a result of the program, adults were 70% more likely to have a regular place of care, “55% more likely to have a regular doctor than the adults who did not gain coverage;” and the utilization of preventative services have increased (Garfield & Paradise, 2013). Furthermore, access to speciality care such as physical therapy; podiatry and hospice remain unattainable. In a multiple city audit, researchers found that only 34% of Medicaid beneficiaries were able to “secure an appointment for urgent” specialist care, compared to 64% of those privately

While there has been large media coverage about the insurance impacts of the Affordable Care Act (ACA), there has been a smaller amount discussed of the law’s changes to provider reimbursement policy, reforms to the delivery system, and investments in programs to improve the quality of care and constrain long-run growth in health care costs. And yet, the elements included in the ACA directed at cost and quality is possible to affect the practice of care for nearly every provider across the country. Although cost containment policies and initiatives are largely applied through federal health programs which including Medicare and Medicaid; cost containment in these programs has important cost-saving spillover effects to private health care markets through changes in health care practices and pricing across sectors of care.

Medicaid-focused managed care has become progressively imperative to state Medicaid organizations. With healthcare reform and the enactment of the Patient Protection & Affordable Care Act (ACA) in 2010, Medicaid will possibly be the main insurer for increasing coverage to millions of low-income, uninsured Americans. Medicaid, a government funded health insurance plan overseen by the state, has supplied coverage for people with disabilities, children, pregnant women, seniors, and the indigent. Managed care plans have aimed to contract with healthcare providers and provide coverage at reduced costs (Smith & Coustasse, 2014). The ACA has helped people become eligible for Medicaid who otherwise would not be able to afford health insurance. There will be more equality between genders, before ACA, the majority of beneficiaries were female. Even though ACA has helped more people become eligible for Medicaid, there are also challenges that have risen due to this as well. The focus of this paper is on the challenges regarding Medicaid managed care and how they can be resolved. The first area discussed will be the history behind Medicaid. Then move on to the challenges of the Medicaid Managed Care Program and how they can be resolved as well as the possible solutions.

In 2010, the United States took the first tangible step toward universal health care coverage, with the legalization of the Patient Protection and Affordable Care Act of 2010. According to the U.S. Census Bureau’s most recent report the total population of the United States is nearly 309 million people (U.S. Census Bureau, 2010). In 2009, it was estimated 49 % of the population was covered under an employer sponsored insurance plan (Kaiser Family Foundation, 2009). The same 2009 data reported an additional 29 % of the population was covered under some form of government or public program (Kaiser Family Foundation, 2009). Leaving 17 % of the U.S. population vulnerable without any form of health insurance coverage (Kaiser

The Affordable Care Act promotes Medicaid expansion. Medicaid expansion is needed in North Carolina to insure the disabled and those that live below the poverty level receive adequate healthcare coverage. The resistance of North Carolina legislature in the promotion of Medicaid reform has retarded Medicaid expansion to its uninsured residents. The cooperation of the North Carolina legislature and its support of the Affordable Care Act is necessary for successful Medicaid reform. This paper reviews the impact of the Affordable Care Act 's lack of implementation in North Carolina.

Medicaid has grown exponentially after healthcare was expanded under the Affordable Care Act. However, this did not guarantee an increase in access to health care services, as many providers do not accept Medicaid beneficiaries, one of many reasons being low reimbursement rates. This discrepancy in rate reimbursement is further underscored when compared to those

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

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.