Managed Care Research Paper

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 this country there are numerous concerns about health care economics. Several factors contribute to the increase of health care costs. One area of concern is the impact of managed care on health care finances. Managed care has been around since the early 1970s. The definition of managed care is a set of contractual and management methods implemented to manage the financing and delivery of health care services. Initial implementation of managed care was for health care cost saving (Getzen & Moore, 2007, p. 203, para. 1). Though Managed care initially addressed several health care finance issues, there are still problems with the current

Managed care has become so popular because of its capabilities to deliver health care at

In recent years, health care has been a huge topic in public debates, legislations, and even in deciding who will become the next president. There have been many acts, legislations, and debates on what the country has to do in regards to health care. According to University of Phoenix Read Me First HCS/235 (n.d.), “How health care is financed influences access to health care, how health care is delivered, the quality of health care provided, and its cost”.

Managed care was born out of necessity. It involves plans, members, providers, and payments intertwined, one not working without the other. With managed care came rising health care costs. Utilization management and quality initiatives were introduced to help control these costs. Medicare and Medicaid were also helpful in setting standards of care which reimbursement is based on as well as providing access to health care for more people. Health care costs continue to rise but with passage of the Patient Protection and Affordable Care Act (ACA) the goal is more people will have access to affordable, quality health insurance while reducing the growth in our healthcare spending.

Medicare and Medicaid are two of the United States largest broken systems, which must sustain themselves in order to provide care to their beneficiaries. Both Medicare and Medicaid are funding by a joint effort between the federal government and the local state government. If and when these governments choose to cut funding or reduce spending, Medicare and Medicaid take the biggest hit. Most people see these two benefits as one in the same, two benefits the government takes out of their pay check to help fund health care. While the government does deduct a sum from paychecks everywhere, Medicare and Medicaid are very two very different programs.

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

Managed care is described in a couple of different ways. The first way that managed care is described would be for financing insurance, delivery, and payments. The second way that it would be described is as an organization that delivers health care services without an insurance company managing how payments are made (Shi & Singh, 2015). There are three primary payment mechanisms used when dealing with different providers which are; capitation, discounted fees, and salaries.

Some people may feel that HMOs have become more involved with insurance and less involved with health care assistance. The government attempt to decrease health care expenses has caused major regulatory changes of the market in health care. Managed care was seen as an effective way to support health care quality while maintaining costs here in the United States. When expectation for limited expenses faded away payors started looking in other directions. That’s when state government turned to managed care as a way of keeping down the cost with less resources available than the federal government. The growth of managed care in the U.S. was sparked by the interest in improving the organization of health care and their outcomes. Managed care will continue to face the everyday challenges of fulfilling the marketplace for less limited care while holding down the

Managed care is and has been consider an effective approach to the quality of health care in America. There is a debate among health care professionals, government regulatory agencies, and the public on how best to reduce the ever escalating health care cost while delivering the best evidence based treatment methodology to our clients. However, with the recent implementation of the Affordable Health Care Act, many health care providers are presented with a daunting task of providing leading edge innovations to their patients within the regulatory restraints placed on them by this act. Also, the future trend of health care is more about accountability to the consumers through the utilization of the consumer driven health plans with emphasis on account Based Health Saving Plans and transparency. The major impact on the delivery of quality care will be that the Affordable Health Care Act and how it will affect how insurance payers implement cost containing restraints, adhere to governmental regulations, and while delivering the best evidence medicine to the clients they serve.

“By 1995, managed care plans had become the dominant form of health insurance and enrolled 73 percent of all Americans who were covered by employer-based health benefits (Jenson, Morrisey, Gaffney, and Liston, 1997)” (Mick & Wyttenbach, 2003, p.6). “In comparing the development of the U.S., British, and Canadian health systems, Carolyn Tuohy (1999: 7) argues that “key

Medicaid is a program designed for low income and disabled people. By federal law, states must provide coverage for very poor pregnant women, children, elderly and disabled. It is jointly financed by the state and federal government through taxes and administered by each state. Coverage varies because states have established different requirements for eligibility; hence people in certain states receive a more generous benefit package under Medicaid than those in other states. In 2010 Medicaid expanded to allow private health insurance companies to offer affordable health insurance to low income people who would not qualify for Medicaid but do not make enough to pay for private health insurance. This was called the Affordable care Act and intended to provide coverage for free to people with income below the federal poverty level. However some states chose not to expand so eligibility in those states are more strict whereas it’s more lenient in states that opted into the Affordable care Act.

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

Looking back, Physicians were chiefly employed by a Fee-for-Service payment model, in which they received payment for each individual service they provided, this in turn supplied incentives for Doctors to provide more treatments causing over-utilization of resources and thrusting healthcare costs into an all-time high and thus managed care was born. In short, managed care refers to "a wide range of financial and organizational models that attempt to control the cost of health care", including the "HMOs, PPOs, IPAs, PSOs, PHOs, IDNs, (Integrated Delivery Networks) and, as Leah Curtin, Editor of Nursing Management, once described them, 'OWAs' (other weird arrangements)" (Huntington, 1997). It essentially shifted the power from providers into the hands of the insurers which slowly pushed physicians away from independent practice and into group practice (Kongstvedt, 2013). Out