Managed Care State Laws and Regulations

The types of managed care are differentiated by definition, operation, structure, and information needs. `HMOs were the most common type of MCO until commercial insurance companies developed PPOs to compete with HMOs' (Douglas, 2003, p.331). `HMOs are business entities that either arrange for or provide health services to an enrolled population after prepayment of a fixed sum of money, called a premium' (Peden, 1998, p.78). There are three characteristics that an HMO must have. The first is a health care financing and delivery system that provides services for members in a particular geographic area. Second, is ensured access to a complete range of health care services, health maintenance, treatment, and routine checkups. Last, health care must be obtained from voluntary personnel that participate in the HMO. The five HMO models related to the participating physicians are the Staff

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.

Intended Impact The ACA also intended to expand Medicaid eligibility and increase Medicaid payments as well as preserving current income eligibility levels for children in Medicaid and the Children’s Health Insurance Program (CHIP). Also, one of the biggest impacts of the ACA was on already existing programs like Medicaid, Medicare, and CHIP. (Teitelbaum & Wilensky, 2013). The individual mandate and employer mandate is in effort to improve the quality of health care received. The ACA also made provisions involving the private insurance market, quality of care and affordability. (Teitelbaum & Wilensky, 2013).

While our understanding has evolved with respect to certain advantages of MCO’s, our understanding of the disadvantages has also grown. This analysis will evaluate the use of MCO’s as a gatekeeper to controlling health care cost and offerings. It will evaluate the advantage MCO’s provide in a rapidly growing market due to the aging of baby boomers. The analysis will evaluate disadvantages that can arise with relying on MCO’s. These disadvantages work against the insurance company forcing a polarizing balance between how much control the MCO should retain over recommendation and provision of services.

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

States have chosen to two forms of Medicaid managed care to better deliver healthcare services besides the traditional fee-for-service Medicaid programs; primary case management and traditional health maintenance organizations. “In primary care case management, the state Medicaid agency contracts with a primary gatekeeper entity (e.g., physician, clinic) that coordinates primary and specialty care for Medicaid beneficiaries. For healthcare maintenance type programs, a State Medicaid agency contracts with an existing healthcare maintenance organization, prepaid health plan, or other institutional health care provider who, in addition to proving primary care services, assumes insurance risk of providing covered services. Typically primary case management are paid on a fee-for-service basis plus a monthly case management fee per enrollee, while health maintenance organization plans are paid a capitation rate and are at full financial risk.” (1)

New England Health Maintenance Organization (HMO) is a regional not for profit managed care company that has its headquarters in Boston, MA, with over 500,000 enrollees within 25 different plans including Connecticut, Maine, Massachusetts, New Hampshire, Rhode Island, and Vermont. A consortium of employers has shown interest in bidding on a managed care contract to be offered to the consortium’s 75,000 employees whom are locate in and around Nashua, New Hampshire. The consortium of employers includes companies such as IBM, Ford, and Prudential Insurance.

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 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.

Managed care and its competition is being viewed to solve their issue on the struggle to control

The challenge between both federal and state authority is how it has been brought up with its federalist structure of American government. Debating over what kind of power should belong to each, most of the power goes to the states under the Constitution to govern daily actions. Since the early 1970s, the federal government has been regulating areas that deal with insurance. However, everything the state does has to be subject to anticipation of the federal government when a lot of concerns start coming into play whether if it about interstate commerce, defense or foreign relations. Fear that states could get overwhelmed with influential lobbying, insurers would seek to weaken consumer protections and raise prices on the insurance. While it has done some good for some over the past few years, Obamacare, or also known as the Affordable Care Act, has helped drop the uninsured rate from 18 to 12.9 percent, allowing more Americans get health insurance However, it is failing to keep the promise of low cost, affordability and care quality. In the long run, Americans will not get the coverage needed to sustain the supposing opportunity of cheap health care. Its flawed political negotiations and trade-offs gives favor to corporate stakeholders in the medical industry over patients and family’s needs for medical support. Having a weak federal oversight of the programs running within the states

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

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.

Generally a fixed premium per enrollee which includes all health care services is provided for in a contract after a negotiated premium between the employers and MCO. As an employee, my company has such an arrangement with a managed Care Organization to finance my dependents’ health care and myself. This has helped to curb the incidents of staying away from work as a result of not having available funds to seek medical attention. It makes it easy and less stressful knowing that my health needs are being taken care of at a time where I may not have enough time when I face health