Managed Care Organizations Essay

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

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.

Health maintenance organizations HMOs - Members must have a PCP who is your general doctor, internist, OB/GYN, or pediatrician. PCP also coordinates cares and makes referrals to specialists. Their main concerns preventive care with a goal of containing overall healthcare cost. It only pays for services performed by in-network provider.

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

Reading Management of Health Care Organizations. Jossey Bass. 2008) draws my understanding that a strategic plan is a product of strategic decision making and indicates organisations direction through its missions and vision statement, objectives and goals, swot and stakeholder analysis. Strategy is a critical element to achieving goals in any organisation. Strategy provides the direction and guides the process of obtaining desired outcomes. The five Ps of strategy plan ploy, pattern position and perspective indicates whether the strategy is short or long term.

Simonet, D. (2005). Medical Practice under Managed Care: Cost-control Mechanisms and Impact on Quality of Service. Public Organization Review, 5(2), 157-176. Doi: 10.1007/s11115-005-0954-8

In chapter 4, I learned about managed care organizations (MCOs), preferred provider organization (PPOs), and health maintenance organizations (HMOs). In PPO there is a list of in-network providers that patients are allowed to see but pay a lot more if they see a physician that is not on the list. In a HMO patients are only allowed to see physicians that are employed by them and may not see anyone else. There are a variety of methods to pay providers for healthcare services. Two of them are widely known as capitation and per diagnosis. Under capitation, organizations receive a fixed amount of money each month regardless of use. In per diagnosis, organizations are paid based on the diagnosis of the patient. The chapter also explained cost shifting

If you are enrolled in a health maintenance organization (HMO) you will need to receive most or all of your health care from a network provider. HMOs require that you choose a primary care physician (most often an internist, family doctor, or pediatrician for your children) who is responsible for managing and coordinating all of your health care.

Health maintenance organization’s (HMOs) use of the primary care physician (PCP) as the “gatekeeper” initially had MCOs view restrictions as a negative approach to patients’ choices. However, some necessary steps have started to be implemented which reduce unnecessary utilization by enforcing some restrictions.

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

In the last four decade, the cost of healthcare services has been on the rise, thereby leading to the promulgation of the Health Maintenance Organization Act of 1973 (Salmon, J. W. 1995). This act provided the opportunity to control healthcare cost, through membership of a provider network that

Critics believe that the present functioning of managed-care is degenerative to health care. Managed-care firms control costs by requiring patients to use a “network” of approved doctors and hospitals, and by reviewing the actions of doctors. Patients have to pay more to visit a doctor who does not participate in the “network.” Managed-care firms second-guess doctors, considering only the costs. Patients are often prevented from visiting specialists to reduce costs. A managed-care company might insist that its doctors prescribe inexpensive generic drugs instead of commercial products. Many patients must, also, receive the insurer’s approval before undergoing treatments or operations. HMOs have been criticized for refusing to pay when a patient goes

Managed care integrates the delivery of health care and financing of health care. In managed care, insurance companies controls the cost, quality, and access of medical care to beneficiaries by limiting the reimbursement levels paid to providers,, by reducing utilization, or both (Beik, 2014, p. 116). There are different types of managed care. Some of the most common types of managed care are Preferred Provider Organization (PPO) and Health Maintenance Organizations. Managed care programs uses different interventions such as economic incentives for doctors and patients, increased cost sharing, controls on inpatient admission and length of stays, and so forth (Deom, Agoritsas, Bovier, & Perneger, 2010, p. 1). On the other hand, managed care tools such as gate keeping, health care networks, second opinion requirement, and pre approval requirement for expensive treatments or hospitalization has changed healthcare delivery on both the macro and micro levels. On the micro level, it greatly impacts the quality of care, cost, autonomy, and relations with patients. According to the research study, managed care greatly affects physicians. It reduces career satisfaction through its impact on doctors’ autonomy and the pressure caused by managed care may affect the doctor’s ability to provide high quality of medical care. (Deom, Agoritsas, Bovier, & Perneger, 2010, p. 7). Like for example, managed care contracting has a positive and negative impact on physicians and patients. The

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.

Under this system, patient must choose a Primary Care Physician (PCP) from a network of local healthcare providers who will refer the patient to in-network specialists or hospitals when necessary. Primary care physician coordinates all care. For example, if the patient has cancer, patient first sees the PCP who will decide where and how to refer him to an in-network provider.