Managed Care Organizations Essay

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.

The Health Care System in the United States has changed throughout the years, the health care delivery system underwent a fundamental change including tighter integration of the basic functions through managed care. Before due to the separations of functions they were not paying close attention to the over utilization and payments for health care that was being used. However due to the high of health care cost today the current delivery system have implemented higher controls over utilization and price, this was been done trough manage care. The functions of managed care are to implement the four basic components of health care delivery, look for methods to control utilization of medical services and to determined at what price services will be purchase and as a result, determines how much a provider gets paid.

Managed care has been formed since the 1930 and evolved over the last ten years. Since the evolving of managed care there are three types of managed care plans. People that are enrolled in private health insurance are subscribed to a type of managed care plan. There are many differences between the three types of managed care plans and they also have similarities. The involvement of managed care plans are between the insurer and the selected network of health care providers, and the policyholder’s financial incentive that are used by the providers in the network. There are precise measures for choosing a managed care plan and conventional

When evaluating a provider's location for accessibility, managed care organizations consider the distance between the provider's location and members, as well as geographical barriers. It is not the intent of a managed care organizations to expend long trips to physicians or hospitals for medical care. For each provider type, the organization also examines typical patterns of utilization and average costs for selected services. Baker comments, "Defining a panel offers managed care plans the advantage of selecting providers with whom they are interested in working as well as the potential to obtain some contracting advantages through which they can sometimes obtain discounts from physicians who would like to be included in the panel" (Baker, 2000, p.3).

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.

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.

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

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

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.

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 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

These plans are known as point-of-service, because each time you need health care (the time or “point” of service), you can decide to stay in the network and allow your PCP to manage your care or go outside the network on your own without a referral from your

If the health care market place continues to consolidate, the defined line of managed health care continues to be blurred. As the health care market demands change, so does the managed health care plans. These ever changing plans are crucial for the survival of managed health care plans and companies (Kongstvedt, 2001).

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.