Managed Care Essay

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

Medicare and Medicaid are programs that have been developed to assist Americans in attainment of quality health care. Both programs were established in 1965 and are federally supported to provide health care coverage to vulnerable populations such as the elderly, the disabled, and people with low incomes. Both Medicare and Medicaid are federally mandated and determine coverage under each program; both are run by the Centers for Medicare & Medicaid Services, a federal agency ("What is Medicare? What is Medicaid?” 2008).

Each state has their own policies for Medicaid eligibility, services and payments. Medicaid plans have three eligibility groups such as categorically needy, medically needy and special groups. Children's Health Insurance Program (CHIP) is a program that offers health insurance coverage for uninsured children under Medicaid. If Medicaid does not cover a service, the patient may be billed if the following conditions have been met such as the physician informed the patient before the service was performed that the procedure was not covered by Medicaid and if the patient has signed an Advance beneficiary Notice form. However, there are also conditions where the patient cannot be billed if necessary preauthorization was not obtained or service

According to the World Health Organization, mental illness will affect approximately 25% of people at some point in their life (“WHO Qualityrights”, n.d.). Despite that, the current mental health care system in the United States is inadequate. Many aspects of the system need improving, especially the barriers to service. In fact, approximately 20% of individuals are left without necessary treatment for their mental health disorder (“Mental Health”, 2016). Mentally ill individuals have difficulty accessing necessary mental health care services for various reasons; insurance, socioeconomic status, and mental health stigma can all function as barriers to treatment. Insurance discrimination can make it difficult for individuals to find treatment (Han, Call, Pintor, Alarcon-Espinoza, & Simon, 2015). Gaps in insurance coverage can also be a barrier, as they disrupt the long-term treatment process (Gulley, Rasch, & Chan 2011). Socioeconomic status has been found to negatively affect appointment scheduling (Kugelmass, 2016). Finally, stigma in our society can also stop people from seeking out treatment that they need (Bathje & Pryor, 2011). The mental health system in the United States is not capable of caring for the mentally ill, as insurance, socioeconomic status, and perceived stigma all act as barriers that prevent people from receiving the treatment they need.

An interesting finding by Huskamp and Iglehart (2016) is that between the Mental Health Parity Act (MHPA) and the Affordable Care Act (ACA), there should be a rise in people with mental illness seeking services, however, services are underutilized more than ever (Huskamp & Iglehart, 2016). According to Bendant (2014), in 2013 a total of 47 million people uninsured and 25% of those suffer mental illness (Bendant, 2014). These numbers are staggering for a service that is more inclusive now more than ever. The Center for Medicare & Medicaid Services (CMS) site indicates that the MHPA is regulated differently depending on the state (CMS, n. d.). The Department of Labor (DOL) has identified a few problems with the MHPA and addressed these issues to Congress via a 2017 report (DOL, n.

To decide on whether or not an issue is considered ethical or moral we need the hard cold facts. Facts expose or explain what is to be decided upon—not what the outcome should be. Decisions regarding health care and mental health issues represent a major portion of ethical and moral choices. As individuals we are not always able to understand the justice, or fairness, behind the decisions supposedly based on hard cold facts.

“One of my biggest struggles with dealing with my ‘problems’ was being able to pay for help. At some points I thought the process to receive help was more draining than my illness itself” (May). Mental illness has plagued millions of people in the United States alone, and with the stigma it carried, getting the help that is needed is not always possible. With Proposition 63 in California it is speculated that with proper aid from the government and community those with mental health problems will be better suited to face their demons. That by having a budget to help those desperately in need we can better the lives of those who struggle with mental illness.

What is managed care? According to the Oxford English Dictionary, managed care is “a system of health care in which patients agree to visit only certain doctors and hospitals, and in which the cost of treatment is monitored by a managing company.” Managed care is a variety of techniques designed to essentially reduce the cost of providing health benefits and advance the quality of care. In the United States alone, there are various managed care programs, that span from less restrictive to more restrictive. As recently stated in the National Institutes of Health, the future of managed care is uncertain. It is enthralling to note that in spite of the advances in the health care systems, such as our hospital’s ability to provide patients

What is left is that we have many citizens who are mentally ill and are not receiving treatment. However the patients who are able to receive treatment are only able to have some treatment covered. Health insurers are responsible for covering the immensely large cost of substantial treatment, a mixture of medication and therapy; since therapy is highly priced, less reliable, and time consuming; patients typically do not receive treatment for therapy. Health insurers would much rather cover medication because it is cheaper, it heals patients faster, and it is more reliable than therapy. However, medication is not made to heal, but to only coax symptoms of a mental illness (Sandberg).

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.

In today’s society there is a greater awareness of mental illnesses. With this greater awareness one might assume that there would be a substantial increase in government involvement or funding in the area of mental illness treatment. Unfortunately this isn’t the case in the U.S. today. There are hundreds of thousands of people with mental illness that go untreated. These potential patients go untreated for many reasons. These reasons are discussed in the Time article “Mental Health Reform: What Would it Really Take.

Historically managed care organizations have not switched mental health patients to less costly forms of treatment, they have just reduced care in general, restricting access to costly medical procedures. (Madonna, 2000, ¶ 12)

Managed care is a system of healthcare delivery that seeks to achieve efficiency by interpreting the basic functions of healthcare delivery. It employs mechanisms to control (manage) utilization of medical services and determines the price at which the services are purchased and how much the providers get paid.

There are great health care benefit programs for employees in most organizations. However, the age limitations are causing serious concerns when it comes to mental care for dependent adults over the age of 26. This needs to change, as mentally ill patients over the age of 26 are left without healthcare insurance; which is never a good thing. Mentally challenged individuals deserve to be protected and covered as dependents under their caregiver’s insurance plans as long as they live. The term dependent should not be restricted to an age, but rather be a term that defines the individual who is unable to provide for themselves due to some mental disorder. Therefore, if organizations change their policies and include the mentally ill as a dependent regardless of age, then, it is likely for economies to see declining crime rates, less cost to taxpayers for essential services, and better overall rehab facilities.

I believe an excellent alternative to the current approach to behavioral health issues would be the incorporation of Telemedicine encounters into the reimbursement schedule for Medicaid patients. If Medicaid and other payers in the industry would take a more proactive approach to the treatment of diseases and illnesses such as substance abuse or PTSD, then there would be more exposure and treatment available to people who suffer from these conditions and it would increase the overall population health in areas where Telemedicine services are provided and encounters with psychiatrists can be conducted via videoconferencing between the patients in their home and providers at their usual location that wouldn’t otherwise have been conducted at all.