Managed Care

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 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.

Another type of managed care program that was introduced is the Preferred Provider Organization (PPO). A PPO is comprised of a group of physicians, hospitals and other medical service providers who contract with employers, insurance companies or other plan sponsors. The PPO offers discounted pricing to these contracted organizations due to the high volume of business received. PPO’s typically have up-front cost sharing in the form of deductibles and/or co-insurance, which vary depending upon the actual plan chosen.

People are aware that managed care has caused patient free will to be lost in the sprint to cut price. Insurance companies in this sense control patients rather than self-monitoring or by a physician. One wants to make their choices. Managed care -whether in the form of HMOs, PPOs, etc., or limits on service- is an attempt by the payers (insurance companies, federal agencies or self-funded groups) to restrict payment for services and procedures the payers consider to be unnecessary

It is composed of its members, plans, payments and providers. The members make up the patients, and every patient has their own "benefits" when it comes to healthcare coverage. Each person's "benefits" varies widely. What it typically means is that the health plan provides coverage for certain types of medical procedures, services and goods. This coverage is provided only under certain circumstances described in the plan. The payments are made by "payers," which manage the "benefits" for healthcare procedures, services, and goods. Basically, what procedures, services, and goods will be paid for, how much they will pay for it, when their "benefits" cover it, and how much the patient will have to pay out of pocket. As for the different types of payers, they range widely from health maintenance organizations (HMOs), preferred provider organizations (PPOs) and managed care organization (MCOs). These types of payers can also be not for profit, for-profit, or member owned. Last is the providers, these are the people and/or manufacturers who perform the services and/or procedures for the patients. The providers then contact the patient’s insurance holders to receive payment for their services. Besides members, plans, payments, and providers, managed care is also composed of manufacturers. They manufacture the pharmaceuticals used, as well as the medical devices. When

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.

Through the use of managed care, HMOs and PPOs are able to reduce the costs of hospitals and physicians. Managed care is a set of incentives and disincentives for physicians to limit what the HMOs and PPOs consider

Today, there are several types of managed care plans including Preferred Provider Organizations (PPOs), HMOs, and Point-of-Service (POS) plans. There are many types of HMOs that offer members a variety of health benefits. An HMO plan requires the member to use health care providers and facilities within the HMO network in order receive coverage, unless it is an emergency (Andrews, 2014, p. 1). A PPO is a form of managed care that most resembles a fee-for-service type situation. The plan members can generally refer themselves to doctors, including doctors outside the plan, although they typically will pay a higher percentage of the cost if the doctor is out of the network (Andrews, 2014, p. 1). A POS plan allows members to refer themselves outside the HMO network and still get some coverage (Andrews, 2014, p. 1). While these

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.

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.

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

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

The both of publications illustrate the relationship and collaboration between public health and managed care, advantages and disadvantages of managed care. If I were the editor of this journal I would select article two for publication for several reasons. Article 2 states a complete and obvious perspective about managed care. It provided a completely definition of managed care and its functions. In addition, it illustrates the convincing example for cooperation between public health and managed care. As mentioned in the article two that the modern public health furnishes many services such as immunization, protection from environmental hazards and so on. Those services cannot be provided without managed care or the health care delivery system.

Introduction. Managed health care is a system that is used to control the financing and the method of delivery of healthcare services to those individuals who are enrolled is specific types of healthcare plans such as Preferred Provider Organizations (PPO) and Health Maintenance Organizations (HMO). Managed healthcare main goal is to ensure that the care that is received by the patient is not just routinely done so that the providers are making a high profit but to ensure that providers are delivery a high quality of care that is also cost effective.