Managed Care Utilization Essay

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.

Utilization management has taken a key role in the health reform act because it evaluates the need, appropriateness, and the efficiency of the health care services which will be used by the covered individual. Health insurance plans are pressured to find ways to reduce plan costs and improve the quality of care provided to their members. Utilization management efforts have reduced inappropriate services and high medical costs just by taking some time to review pre-authorizations instead of providing clinically inappropriate, out-of-network services which prevents the accurate care for patient and increases cost for plans. Today’s decision-making and support of utilizations for members are performed in real-time. Real-time utilization achieves the decrease of unnecessary expenses and improves member’s health. Use of unnecessary services increases the cost for plans and limits them on the amount of services they can provide to members who are in dire need of them.

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

To decide on whether or not an issue is considered ethical or moral we need the hard cold facts. Facts expose or explain what is to be decided upon—not what the outcome should be. Decisions regarding health care and mental health issues represent a major portion of ethical and moral choices. As individuals we are not always able to understand the justice, or fairness, behind the decisions supposedly based on hard cold facts.

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

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”.

The concept generates images of large healthcare entities managing the administrative protocols of prior authorization or denials to the actual delivery of care through a facility or network of healthcare providers. Hacker and Marmor (1999) described several meanings of the term managed care with the most applicable to the menagerie of forms managed care can take being a combination of the financing and delivery of healthcare services. While this particular study is dated, the authors contend any managed care structure features administrative oversight, patient steerage to a particular provider entity or network and the amount of risk-sharing whether at an individual or group level. These features continue to be true today as organizations explore the benefits offered to employees through managed care structures such as preferred provider organizations, clinically integrated networks, and accountable care organizations. As a healthcare provider, the goal is to provide access to healthcare which is affordable, offers access to providers of choice and engages with providers who provide the highest quality

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

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.

In 1983, the Medicare prospective payment program was implemented which allowed hospitals to be reimbursed a set payment based on the patient’s diagnosis, or Diagnosis Related Groups (DRG), regardless of what treatment was provided or how long the patient was hospitalized (Jacob & Cherry, 2007). To keep the costs below the diagnosis related payment, hospitals had to manage efficiently the treatment provided to a client and reduce the client’s length of stay (Jacob & Cherry, 2007). Case management, or internal case management “within the walls” of the health care facilities was created to streamline costs while maintaining quality care (Jacob & Cherry, 2007).

Managed care has a huge impact on the united states health system. Managed care is simply the qualitative care and costs effective heath care management in US health system. Many US citizen who is not getting proper treatment for their disease and disorder are greatly benefit from managed care. As managed care increase in improving health care services, low income family member is hugely impacted by it. managed care is cost effective in which lower the cost of service and get high quality of treatment from the provider. Even though managed care beneficiaries to many of US citizen to obtain qualitative health care from the provider, they have a hard time on finding out the accurate primary care provider who is associate with insurance. Managed care is one of the best cost saving or

Utilization management is described as the implementation of guidelines which reduce unnecessary use of medical resources (Kongstvedt, 2007, p.190). There are a variety of methods used to ensure costs are kept at a minimum without compromising patient care. The use of utilization management (UM) are yielding financial benefits resulting in managed care organizations (MCOs) and facilities investing more into UM programs.

The presence of managed care organizations in a health care market creates incentives that affect provider treatment patterns for both managed care and non-managed care patients. The mechanisms may include

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.