Managed Care Research Paper

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.

Throughout the last half of the 20th century, employers have acted on their own to regulate health costs by requiring employees to join health maintenance organizations (HMOs). More than 100 million Americans are under managed care. However, many patients and doctors complain that HMOs impose too many regulations and sacrifice healthcare quality. HMOs are undergoing a high level of scrutiny due to criticisms that the network is controlling and jeopardizing the healthcare system of the nation.

Managed care will always be prevalent in the United States because of the strong foundation that was created decades ago. How could doctors and hospitals create and maintain viable practices and at the same time make innovative advancements in medicine? They needed a system

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

In an attempt to understand the impact of managed care in the U.S, I look at the most commonly expressed complaints against the organization. In a survey of consumers, 60% said that managed care had not made a difference in health care cost or had actually been the cause of the increase of health care cost. Managed care has had an impact on slowing the rates of growth in the costs of two major health care producers: hospitals and physicians. Little evidence has suggested that the current reimbursement are inadequate to the care provided. The quality of care is a highly debated issue. Physicians are concerned that the quality of care in managed care organizations may reflect the loss of professional autonomy through pre-authorization procedures.

rising health care costs. Managed care can be defined a system of delivering health services in

At one point, managed care was the viewed as a resourceful tool in efforts to help assist employee, physicians and hospitals with quality health care, while controlling the cost of medical care in the United States. Over the past 30 years, managed care has been in the limelight of health insurance, as a dictator of how it will pay for medical bills. There have been many factors playing a role with managed care over the years. For example, due to the slim selection of options that are available with physicians in rural areas, and limited physicians to choose from, does this compromise the quality of care of each member or does this cut off services for members

“Managed care embodies an effort by employers, the insurance industry, and some elements of the medical profession to establish priorities and decide who gets what from the health care system.” (JAMA.2001; pg. 285:2622-2628). Manage Care is part of the Health Care system since 1973 is known as the system that finances and delivers health care to individuals enrolled under their plans. Manage care is intended to reduce the unnecessary health care cost in America through a variety of mechanism that includes medical necessity review programs, economic incentives for physicians, beneficiary cost sharing, control of

The expanded health insurance coverage via the Affordable Care act is having a major effect on managed care hospitals in many avenues. These effects are impacted via the increase in demand for care, the increase of patient revenues, as well as a lower uncompensated care especially for the uninsured. Not surprisingly, the constraints as well as the controls that are being imposed by the managed care have lead to an outrage by the doctors and their patients. Managed care in the United States finds itself under attack from every side. As far as the managed care organizations are concerned, administrators are unease regarding the profitability or the surplus for reinvestment and even the consumers are also worried about the possible closure of hospitals (Goodson, 2010). Managed Care Organizations have been forced to reduce hospital utilization even though there have also been a few facility closures.

Medicare is administrated by the Centers for Medicare and Medicaid Services (CMS). It is divided by subdivisions which is the Center for Medicare Management who overseas development of payment policy and management of fee-for-service contractors. The Center for Beneficiary provides beneficences with information on Medicare programs, and research grievance and appeal functions. The Center for Medicaid and State Operations focuses on federal and state programs like Children’s Health Insurance Program and the Clinical Laboratory Improvement and CMS who enforces insurance portability and transaction and code set requirements of HIPAA.

Healthcare expenditures have more than doubled since 1965. Americans spend over a trillion dollars a year on health care. (2). As of 1996, 110 million Americans were enrolled in HMO's. More than three-fourths of all individuals in HMO's are covered by job-based insurance. More than 13 million Medicaid recipients have been put into managed care plans. Managed care and HMO's have been the subject of many negative stories in the press and are constantly being charged with endangering the health and lives of their enrollees. As a result, congressional hearing, state, and federal regulation, and action by the

Managed care has been around since the twentieth century, which managed care has continued to develop. Therefore, the definitions of managed care may vary from different scholars and/or textbooks. As a result, one meaning of managed care is to provide health care services at a reduced rate to members of an insured group through an agreement among specific suppliers and an insurer (Ereflect, 2009). Furthermore, some relevant scenarios for the meaning of managed care are the ability to increase access to a variety of healthcare services, managing medical practice, curbing medical spending, and restricting physician entrepreneurialism (Rodwin, 2010). In addition, managed care has been used by the states and private entities to promote diverse goals (Rodwin, 2010). Therefore, the initial growth of managed care was partly

An interesting perspective in regards to regulation is offered by; Academy for Health Services Research and Policy. The observations were presented for review on August 2001. The informative article is appropriately titled: The Challenge of Managed Care Regulation: Making Markets Work?

The HMO could oversee and approve physician decisions such as whether to admit a patient, how long to keep the patient in the hospital, and whether to order expensive diagnostic tests for the patient, all of which heretofore had been made autonomously by physicians. The HMO “managed” care, with the goal of limiting high costs due to overutilization, without compromising patient outcomes. In the next three decades, health insurance plans adopted tactics introduced by the HMO model to limit expenditures and health care use. Managed care grew to encompass 97% of the employer-sponsored health insurance market, which represents approximately half of all insured Americans (Bradley and Taylor, 2013). Since the managed care systems lowered costs, Medicare and Medicaid programs also began to increase their managed care tactics, instituting greater control over physician and hospital decision-making, to further rationalize their spending. Thus, managed care efforts began to slow the acceleration of health care costs during the 1990’s; however, this attenuation could not be sustained. Public complaints of overly harsh rationing by managed care companies reduced their popularity in the employer insurance market and cost acceleration resumed in the early

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