Managed Health Care Analyzed 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.

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

Millions of Americans use the services of health care officials on a daily basis. To aid in the increasingly high financial costs of these services, many people rely on the government, insurance companies, and other parties through managed care organizations (MCOs) (Potter & Perry, 2017, p. 15). A MCO “provides comprehensive preventive and treatment services to a specific group of voluntarily enrolled people” (Potter & Perry, 2017, p. 16). With the implementation of the Affordable Care Act (ACA), the government faces ongoing struggles to use valuable resources within the health care system to continually maintain problematic MCOs. Therefore, the administration of health care services has been greatly impacted by the ACA, bringing about

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.

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?

In recent year the health care industry has seen broad changes that have impacted all health care stakeholders. Often, leaders in health care believe that external factors which affect the industry, such as local and federal policies, payers, cost of doing business, technology, health of the population etc, are so powerful and so far outside of their control that whatever strategy they employ, it will not be able to counterbalance these external forces and therefore will not generate new demand and create new markets. These leaders are stuck in what Chan and Mauborgne call mental models designed to negotiate existing market spaces, which prevent them from creating new markets. They spend their time fighting to keep their patients away from

This paper provides an overview of managed health care in the United States, what types of plans are available and their benefits, and drawbacks.

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

Health care organizations are complex entities whose theory and structure have evolved and transitioned over time. In the late 1980s and early 1990s health care experienced a paradigm shift as managed care organizations guided health care practices by managing the care between patients and physicians in order to drive down health care costs. This transition has created controversy and discontent as physicians, patients and payers balance what is required to ensure quality care. The movie Damaged Care introduced the organizational structure of the managed care organizations, the hierarchy of care within the organization, the power struggle within those organizations and the impact it has on the clinical decision making and ultimately the patient. This paper will analyze the organizational theory that drives the managed health care, the roles and motivators of all parties involved and the effects organizational actions have on the consumers’ care.

Health care organizations are complex entities whose theory and structure have evolved and transitioned over time. In the late 1980s and early 1990s health care experienced a paradigm shift as managed care organizations guided health care practices by managing the care between patients and physicians in order to drive down health care costs. This transition has created controversy and discontent as physicians, patients and payers balance what is required to ensure quality care. The movie Damaged Care introduced the organizational structure of the managed care organizations, the hierarchy of care within the organization, the power struggle within those organizations and the impact it has on the clinical decision making and ultimately the patient. This paper will analyze the organizational theory that drives the managed health care, the roles and motivators of all parties involved and the effects organizational actions have on the consumers’ care.

Managed care has influenced and changed the ways in which healthcare providers make medical decisions. With the introduction of managed care, the control of the decision making has shifted from the physicians to the managed care organizations (Fottler & Malvey, 2004). Managed care has been accused of focusing more on costs and profits than on patient care. After a decade of cost management and distribution of cost savings to investors, administrators and employers will yield to legal, employee, patient, and provider pressure for access. In fact, financial cuts influence providers' decision, for example, to cut staff and to replace expensive and experienced staff with cheap inexperienced staff. Physician loss of freedom to make medical decisions, and to implement those decisions, breeches the doctor-patient relationship. This theft of autonomy, but persistent moral and legal burden of responsibility for patient care has demoralized physicians.

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.

Managed care. (2009, March 8). In Wikipedia, The Free Encyclopedia. Retrieved 19:31, March 14, 2009, from