The Organizational Theory That Drives The Managed 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 is known for being one of the most costly systems in the world. In 2010 the Affordable Care Act, (ACA) was implemented with the hopes of reshaping the system and decreasing the healthcare cost, (Mason, Gardner, Outlaw, O’Grady, 2016). . Somewhere along the way our country made healthcare a business. Understandings our country healthcare finances can be quit complex. In order to be successful the Chief Nursing Officer, (CNO), business owners and directors must understand the business principles. These individuals are placed in leadership role and therefore must have the characteristics of a leader, (Huber, 2014)

A Health care system of any country is an important consideration for the purposes of the overall development. One of the most important and essential feature of the human body is the health and the systems. In the same manner, proper management is also necessary. Furthermore, all the countries of the world have few targets and achievements to be made. On the other hand, it should also be noted down that, economic development and social welfare the two most are the two important factors. Economic welfare is connected with the increase in the wealth of the people at large (Niles, 2011).

"In the past two decades or so, health care has been commercialized as never before, and professionalism in medicine seems to be giving way to entrepreneurialism," commented Arnold S. Relman, professor of medicine and social medicine at Harvard Medical School (Wekesser 66). This statement may have a great deal of bearing on reality. The tangled knot of insurers, physicians, drug companies, and hospitals that we call our health system are not as unselfish and focused on the patients' needs as people would like to think. Pharmaceutical companies are particularly ruthless, many of them spending millions of dollars per year to convince doctors to prescribe their drugs and to convince consumers that their specific brand of drug is needed in

Our healthcare system is in a state of constant change. Just as the industry was adapting to the demands of countless healthcare reforms, the fate of regulations like the Affordable Care Act (ACA) and others like it, dangle in the wind. As the country transitions to a newly appointed administration, there is an increasing level of uncertainty among industry leaders. Federal, state, and local mandates continue to drive the need to improve the quality, costs, and outcomes of care which add to an already overburdened and burnout system. These coupled with our highly secular society who is primarily focused on the treating and curing illness through advanced technology, medications, and procedures has resulted in a

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 case of Ledina Lushko, a patient enrolled in a Blue Cross and Blue Shield of Illinois individual plan, highlights many of the issues that have plagued the United States healthcare system for some time. As an insurance plan provider, BCBS of Illinois takes pride in the health outcomes of our members and has a responsibility to contribute positively to their care. The fractured, ineffective care Mrs. Lushko received is disappointing, however, this case provides strong support for a shift in focus towards managed care and specifically, the Accountable Care Organization structure. The following details several aspects of Mrs. Lushko’s experience and how her care could have been improved by enrollment in BCBS of

Managed Care is a system of health care in which patients agree to visit only certain doctor and hospitals, and in which the cost of treatment is monitored by a managing company. David, a clinical supervisor of one pad was responsible for the clinical supervision of eight clinical case managers. On typically day, he receives around 40 phone messages about clients that are in need of his services. His job is to field calls from mental health providers seeking authorization to provide treatment for clients. There are those who believe that managed care is simply another example of corporate America discovering a means to increase profits for shareholders of insurance companies, at the expense of individuals seeking mental health treatment. (pg.

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

This paper seeks to look into organizational behavior in health care management and most importantly its impact on health care management and delivery. Organization behavior is crucial in guiding the regulatory activities, the staff activities and the overall culture that directs an organization. Organizational behavior in health care setting is paramount to ensuring patient safety, ethical behavior among the medical practitioners, patient-centered care and effecting change in the facilities which is bound to improve healthcare delivery and patients’ satisfaction. The strategic management of any health

The United States has a unique system of healthcare delivery, it is complex and massive. Twenty-five years ago; American citizens had guaranteed insurance, meaning the patient could see any physician and the insurance companies and patients would share the cost. But today, 187.4 million Americans have private health insurance coverage (Medicaid, 2014). The subsystems of American health care delivery are Managed care, military, vulnerable populations and integrated delivery

This paper provides an overview of the healthcare environment and its financing in the U.S. and define acute care and long term care. It addresses three important issues. First, it provides a snapshot of how health care is currently financed in the United States, including the differences and/or similarities between Managed Care Organizations. The second part of the paper examines the current federal government programs and various types of access to health care available to every citizen. The third part of paper examines the implications nurses have in

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.