Problems with HMO's 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

A part of the problem of cost was the establishment of “free” healthcare for those eligible for Medicare and Medicaid, between 1965 and 1971 where there was no limitation on benefits. The cost of healthcare increased from 39 billion in 1965 to 75 billion in 1971. Providers had no concern for the cost of their care seeing that SSA recipients had no limits

Since its establishment in 1965 we have seen Medicare change as people’s needs change however being a federal program these changes do have an incredible amount of lag time. One of the first major changes to Medicare occurred in 1972 when President Nixon signed the Social Security Amendments of 1972 which extended coverage to individuals under age 65 with long-term disabilities, expanded benefits to include some chiropractic services and speech and physical therapy. During this time we see the American public growing tired of the Vietnam Conflict and lack of support and care for those returning Marines and soldiers with severe disabilities. As the protests escalate and the peace initiatives fail a key piece of legislation is signed showing government support and a willingness to extend health care benefits to this growing and vocal population of veterans (The Vietnam War, 1999). Also included in this Amendment is the encouragement of the use of Health Maintenance Organizations, President Nixon’s administration caught in the scandal of Watergate and pending hearings appeased the left and proposed the HMO Act, which Congress passed in 1973 (Phillips, 2003).

Rising health insurance premiums have made healthcare unaffordable in the United States. Health insurance premiums in this country have undergone a steady rise over the past few years while incomes have remained the same. More than 50% of individuals with low incomes holding private insurance in the United States are unable to afford their healthcare costs (Collins, Gunja, Doty & Buetel, 2015). In addition, costs related to healthcare are equally unaffordable to 25% of working-age individuals who hold private health insurance policies (Collins et al., 2015). According to the Kaiser Family Foundation/Health Research and Educational Trust (Kaiser/HRET) survey on employer health benefits, employer-sponsored health insurance plans have also had moderate rises in premiums in 2013 for both individuals and family coverage (Claxton et al., 2013). While

What’s next? Some experts say that if the consumer-directed approach doesn’t succeed, em wash their hands of health care altogether. A recent study by the Employee Benefit Researc showed that the proportion of U.S. residents covered by employment-based health benefits d percent in 2000 to 60 percent in 2004. Decades from now, observers may conclude that a counter- revolution in employer coverage began in these early years of the 21st century. —Terence F. Shea

There has been discussion to have universal healthcare system similar to Medicare as a method to have a centralized monitoring system of cost. There have also been other systems tried beginning with HMOs in the 1970s in an effort to streamline access to necessary healthcare services by employing a gatekeeper to their access at the primary care levels. With patient dissatisfaction, PPOs were tried which circumvent the necessity of referrals (Hacker, 1998). Either of these models had substantial effect on healthcare outcomes while the cost of healthcare continued to skyrocket. The US spends more than any other country on healthcare but outcomes are not better (Blackstone, 2016). In 2010, under President Obama’s leadership, Affordable Care Act was passed and one of the promising features is the formation of accountable care

HMOs are usually the least expensive health plans, offer predictable costs for health care, the least administrative paperwork, and cover preventive care (Barsukiewicz, Raffel, & Raffel, 2010). However, HMOs also restrict direct access to specialists by requiring referrals by a PCP, requiring patients to see a provider in the HMO network, and often not covering more costly procedures or care options, because care is managed to control excessive or unnecessary care. Providers gain if they provide less care (Austin & Wetle, 2012). This incentive could affect patient-provider trust.

People are aware that managed care has caused patient free will to be lost in the sprint to cut price. Insurance companies in this sense control patients rather than self-monitoring or by a physician. One wants to make their choices. Managed care -whether in the form of HMOs, PPOs, etc., or limits on service- is an attempt by the payers (insurance companies, federal agencies or self-funded groups) to restrict payment for services and procedures the payers consider to be unnecessary

Many people are concerned about rising health care costs. In reaction to this, some individuals and companies are gravitating toward the assumed lower prices of Health Maintenance Organization (HMO) health plans. HMOs spend billions of dollars each year advertising their low cost services. While these savings look good on paper, there are many pages of small print. The explanation after the asterisk indicates that not only do the HMOs lack lower costs, but they also short-change the patient in quality care. Much of the money spent on premiums goes directly into the pockets of stockholders and less is then available for

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.

Through the use of managed care, HMOs and PPOs are able to reduce the costs of hospitals and physicians. Managed care is a set of incentives and disincentives for physicians to limit what the HMOs and PPOs consider

In an attempt to understand the impact of managed care in the U.S, I look at the most commonly expressed complaints against the organization. In a survey of consumers, 60% said that managed care had not made a difference in health care cost or had actually been the cause of the increase of health care cost. Managed care has had an impact on slowing the rates of growth in the costs of two major health care producers: hospitals and physicians. Little evidence has suggested that the current reimbursement are inadequate to the care provided. The quality of care is a highly debated issue. Physicians are concerned that the quality of care in managed care organizations may reflect the loss of professional autonomy through pre-authorization procedures.

Having been instituted on July of 1965 by President Lyndon, Johnson, for 50 years now, Medicare has served as a means of of health insurance for individuals 65 and above. This program has served as a means of getting healthcare to the elderly despite their financial situation. Going back as far as 1912, America had long been aspiring to establish a health insurance policy for Americans, but alas, none of these projects ever got real momentum. That was until 1945 when Harry Truman was elected into office. Truman believed health care for every American was an urgent matter so he requested that congress create a National Health Insurance Policy, which would help every American pay for meticulous things such as routine doctor visits, dental care, and other necessities. Despite his dedication, Truman’s plan deteriorated and nothing was accomplished. Finally, in 1965, Lyndon B. Johnson signed for legislation to establish what we all know today as Medicare.Since then, the program has experienced countless changes coming to cover far more Americans. At the time, it only consisted of Part A and B, but over the years, but has come to include C and D as well. Despite having been created in order to help a wider population, the program has been proven to have aspects of it that ultimately harm consumers.

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

Less than a hundred years ago, in the late 1920’s and 30’s, almost 90% of Americans did not have health insurance (Fall of HMO’s 4). They used a variety of home remedies and when medical assistance was truly needed, they paid for it out of pocket, even incurring vast amounts of debt. This had been the case throughout history, and it changed due to an important factor, medical equipment. The industrial revolution finally caught up with the medical industry and the country saw a vast change in the scientific instruments used by physicians. These instruments required a lot of money to make and care for which caused prices to rise. Due to this massive problem, a committee was formed of health care professionals and after a 5 year study, the Committee on the Cost of Medical Care suggested that health insurance co-operatives start. These corporate medical practices became known as Health Maintenance Organizations (HMO’s) and preferred provider organizations (PPO’s), and up until the 1970’s, were an experiment to regions across the U.S. Factors that hindered health care included bullying of “money politics” from both sides of the isle as well as Presidential views and tactics as well. President Nixon first