Managed Care Through The Delivery Of Health Care

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

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.

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.

The HMO’s stress wellness and preventive care, therefore its focus is more on health maintenance rather than just the treatment itself. Because of this, HMO’s offer much richer benefits than the traditional plans. HMO’s have little to no upfront costs in an effort to encourage maintenance, while comprehensive and major medical plans have up-front cost sharing so as to discourage over utilization.

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

The book discuss about three major types of managed care organization: health maintenance organizations (HMO), preferred provider organizations(PPO), and point of service plans(POS). Managed care has been around for minute. This organization has been around since 1930s. The three managed care organizations are require an agreement between the insurer and a network of health care providers. Policy holders are encouraged to use the providers in the network by the fact a percentage will pay the cost of care if received outside the network.

Managed Care is a complex health care system in which physicians, hospitals, and other healthcare professionals organize in an interrelated system of people and facilities that communicate with one another and work together as a unit, commonly referred to as a network. This network coordinates and arranges health care services and benefits for a specific group of individuals, referred as enrollees, for the purpose of managing costs, quality, and access to health care. The Managed care program may be provided in a variety of settings, such as Health Maintenance Organization (HMO) and Preferred Provider Organization (PPO). In Health Maintenance Organization, the insurance company will only pay for care within the network. The member will pick a primary care provider who coordinates most of their care. Preferred Provider Organization (PPO) usually pays more if the member will get care within the network, but they still pay a portion if the member will go outside. And Point of Service (POS) plans let you choose between an HMO and a PPO each time you need care (Merrick, 2013).

“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

Managed care has turned into the name for a change in the way health care is organized and financed in the US. Now a day the health care system is not just difficult, it is essentially unique in relation to what it used to be. The progressions are numerous and speak to the real moves required in moving from an indemnity plan, founded fundamentally on what the patient needed, toward a managed care system. The American human service has experienced radical changes inside two eras and keeps on developing. The federal legislation that I have chosen that most significantly influenced the growth of managed care from my point of view are the HMO Act of 1973 and HIPAA.

Change is inevitable when it is a faltering system; such as health care and insurance, which means in the health care industry there is nothing constant in the contemporary managed care systems. When speaking of managed health care, some find it to be an institution set forth as a response to the consistently rising health care costs, that some viewed as detrimental to the United States economy as a whole. Others viewed managed care as a documented response to health care quality problems that have long been ignored. That the problems managed health care would specifically help rectify patterns of over and underuse, misuse, and any geographic variation in the medical services provided to citizens (Kongstvedt, 2001). Both of these ideals had a hand in the wide spread adoption of managed health care in the United States, they do not define the foundational and personal changes that needed to occur in order to accommodate such a large change. However, following the introduction of the health maintenance organizations or HMO’s there has been an over flow of managed care programs and products being created in the United States.

Managed care programs remove the majority of the consumer-driven or free market provider selection and health care choices by establishing networks with preapproved providers. These programs include health management organizations (HMOs), preferred provider organizations (PPOs), point-of-service (POS) options and provider- sponsored organizations (PSOS), of which are all network based (Gage, 1998). Patients who utilize a managed care program find there is little or no cost for receiving care within the network, however, require referrals to see a specialist, high cost if a physician is outside of the network, requirements of second opinions for costly procedures/ diagnosis, and pre-defined hospital stay limits. On the other hand, physicians supporting managed care programs contract and accept various risks, including insurability, utilization rate, price, reimbursement rates and legal risk (Brown & Reiss, 2000) for the

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

To begin, the term “managed care” refers to health insurance plans designed to provide healthcare at the absolute lowest possible cost (Bodenheimer, 2001). These plans include PPO (Preffered Provider Organizations), HMO (Health Maintenance Organizations), and POS (Point of Service Plans). PPOs are a group of providers and hospitals that have agreed to accept lower costs for the care provided, as long as the patient remains within the network of providers; closely resembling a “Fee-for-service plan” (Bodenheimer, 2001). An HMO is slightly different in that it allows members an array of provider choices for a set monthly fee. However, the providers must be within the network. Additionally, HMOs focus on preventative care and typically offer routine

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.