Private Insurance 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 America, the number of uninsured rises every year and no solution to the problem has

Health insurance comes as second nature to many of us. We grab that blue and white card and put it in our wallet and forget about it until we are sick or injured. When this happens, there it is, cushioning our fall like the extra padding it provided to cushion our wallets. This is not the case with everyone, however. Many Americans have no cushion to fall back on, no blue and white card to show the emergency room when they have an unexpected health concern. No HMO with a convenient co-pay amount when their son or daughter develops an ear infection.

Private health insurance plans frequently are offered through a person’s job. When an individual acquires health insurance this way their workplace covers part of the cost for their insurance. Frequently, they are offered different plans for different prices. Once these plans are chosen, typically, a premium fee will be deducted from that person’s pay checks (Colorado.Gov, 2015). On top of these premiums the individual will also have other fees such as co-pays, deductibles, or co-insurance (Colorado.Gov, 2015). Private plans can also be purchased without an employer’s help, the individual will be expected to cover the premium payment of the plan as well as all of the matching extra fees (Colorado.Gov, 2015).

In 1954, Congress passed legislation allowing employers to provide health insurance benefits to employees on a tax-free basis (Sih and Singh 99). This legal provision marked the beginning of the rapidly expanding health care costs still apparent today due to the major incentives provided by the government to obtain employer-based health coverage. The overwhelming popularity of employer-based health insurance has led to a serious market inefficiency resulting from the system of third-party payment. As individuals rely on their insurance companies to pay for their medical expenses, this provides

Each state has their own policies for Medicaid eligibility, services and payments. Medicaid plans have three eligibility groups such as categorically needy, medically needy and special groups. Children's Health Insurance Program (CHIP) is a program that offers health insurance coverage for uninsured children under Medicaid. If Medicaid does not cover a service, the patient may be billed if the following conditions have been met such as the physician informed the patient before the service was performed that the procedure was not covered by Medicaid and if the patient has signed an Advance beneficiary Notice form. However, there are also conditions where the patient cannot be billed if necessary preauthorization was not obtained or service

"Insurance is a legal contract that protects people from the financial costs that result from loss of life, loss of health, lawsuits or property damage."(Nielson.) This protection is given to the customer in exchange for a monthly payment to the company. This is a legal contract which is known as a policy, binds the customer to the insurance company for the duration of the policy. Insurance, whether it be life, health or auto, helps customers feel safe from everyday risks that can happen in life. Most insurance is optional, although some states enforce a law that automobile insurance must be purchased in order to register a car. Automobile insurance is very important. It helps the policy holder to protect their car

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.

One of the greatest changes in healthcare in the past ten years has been the rise of managed care, much to the displeasure of many patients and physicians alike. Managed care arose out of concern about spiraling healthcare costs and was designed to encourage physicians to give patients treatments that were cost-effective out of their own financial interests. "The consumer strategy was directed at imposing some barriers to use by levying various forms of co-insurance. The most common approaches used either deductibles (where the consumer paid the first portion of the bill a technique familiar in other types of insurance) or co-payments (where the consumer paid a portion of the bill and the insurance company the rest) or a combination of both' (Kane et al 1994). Managed care has given health insurance companies an increasingly significant voice in how treatment is administered and allocated. Managed care has proliferated in the past decade despite considerable criticism of the practice of 'nickel and diming' patients as well as the considerable bureaucratic red tape it is has generated. Also, research indicates that healthy, well-insured patients tend to over-consume care without meaningful co-pays but poorer, sicker patients can be deterred even by moderate co-payments and suffer negative health consequences (Kane et al 1994). However, managed care has not gone away and is a reality that all healthcare

A High Deductible Health Plan (HDHP) is a health care plan in which they monthly premium (amount that is paid by the consumer monthly or annually) is lower, but the insured has higher out-of-pocket expenses. Out-of-pocket expenses or deductibles are the financial cost that the individual pays on their own before their insurance pays its share ("High Deductible Health Plan (HDHP) - HealthCare.gov Glossary | HealthCare.gov," n.d.). With the help of these HDHP, individuals also combine a Health Saving

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

ticle- Traditionally employers provide health coverage to workers by plans offered through insurance companies which again collect from workers in the form of premiums and deductibles. But a major drawback is with raising health costs proportionately raises the premiums. According to CMS, During 2016 health care spending on workers in private business has increased by 6.1 %, in contrast government spending has increased only 4.5 %.

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.

Most health insurance is extensive, and can be anything from vision services and counseling, to receiving prescription medications, non-emergency ambulance services and hospital treatments. This is a welcome addition and relief for those who cannot afford outside policies that may be more specific or expensive. Awareness of and attaining quality health insurance is also becoming more of a priority among younger people in the work force as unforeseen complications have risen on the job over cumulative scales in recent