Trends In Managed Care

The types of managed care are differentiated by definition, operation, structure, and information needs. `HMOs were the most common type of MCO until commercial insurance companies developed PPOs to compete with HMOs' (Douglas, 2003, p.331). `HMOs are business entities that either arrange for or provide health services to an enrolled population after prepayment of a fixed sum of money, called a premium' (Peden, 1998, p.78). There are three characteristics that an HMO must have. The first is a health care financing and delivery system that provides services for members in a particular geographic area. Second, is ensured access to a complete range of health care services, health maintenance, treatment, and routine checkups. Last, health care must be obtained from voluntary personnel that participate in the HMO. The five HMO models related to the participating physicians are the Staff

Even though within the Managed care trends there have been many rapid transformations throughout the years with the HIPAA laws enforcements throughout health care facilities within the United States and Obamacare. Currently, there are challenges ahead with the healthcare reform due to the new presidency stirring up changes with health insurance and getting rid of Obamacare. Throughout the managed care trends chronic condition management have affected two-thirds of the baby boomer’s generation causing them to have chronic health conditions that them to receive medical treatment constantly with elevated health care cost. Next, a trend of having the options available for mobile health has grown tremendously by allowing many a chance to gain access

Expansion of the MCO model occurred with the enactment of the Health Maintenance Organization Act of 1973. This Act provided the foundation for managed health care and required employers with greater than 25 employees to provide and HMO offering. The Act served to counter Democratic efforts to nationalize U.S. health care and to stimulate competition within the health care market. HMO’s also began the concept of for profit health care operations. While most health care providers are not for profit (Phelps, 2011) and number operate under a for profit model. Non-profit dominates the healthcare sector based on their tax exempt status.

Another type of managed care program that was introduced is the Preferred Provider Organization (PPO). A PPO is comprised of a group of physicians, hospitals and other medical service providers who contract with employers, insurance companies or other plan sponsors. The PPO offers discounted pricing to these contracted organizations due to the high volume of business received. PPO’s typically have up-front cost sharing in the form of deductibles and/or co-insurance, which vary depending upon the actual plan chosen.

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

This paper examines the benefits and issues with managed care. The benefits include patients receiving preventative care, lower premiums, lower costs of prescriptions, fewer, unnecessary procedures, and less paper work. Some issues with managed care include limitation on doctors that patients can choose from, restricted coverage, the possibility of under treatment, and compromised privacy. Managed care effects nursing by causing significantly few jobs for registered nurses, more opportunities in non-acute health care settings, and more use of advanced practice nursing.

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.

Today, there are several types of managed care plans including Preferred Provider Organizations (PPOs), HMOs, and Point-of-Service (POS) plans. There are many types of HMOs that offer members a variety of health benefits. An HMO plan requires the member to use health care providers and facilities within the HMO network in order receive coverage, unless it is an emergency (Andrews, 2014, p. 1). A PPO is a form of managed care that most resembles a fee-for-service type situation. The plan members can generally refer themselves to doctors, including doctors outside the plan, although they typically will pay a higher percentage of the cost if the doctor is out of the network (Andrews, 2014, p. 1). A POS plan allows members to refer themselves outside the HMO network and still get some coverage (Andrews, 2014, p. 1). While these

Managed care has been adopted into the government funded care organizations. Medicare managed care plans provide all coverage themselves, including basic Medicare coverage. Managed care plans cover above and beyond the basic benefits of Medicare, the size of premiums and copayments, and the decisions about paying for treatment are controlled by the managed care plan. The basic premise of managed care is that the member/patient agrees to receive care from only a specific doctors and hospitals, in exchange for reduced healthcare costs. Medicare, like other insurance companies offer plans that give Medicare beneficiaries more choices in coverage, like HMO or PPO. Managed care has been used since the mid 1990’s in order to provide healthcare to beneficiaries with serious or life long illnesses. Today, managed care has become a way for states to provide quality care to both Medicaid and Medicare patients.

rising health care costs. Managed care can be defined a system of delivering health services in

The relationship of an HMO and its physician member is to help provide a wider range health care for its patients and a wide area of services available for its physician members. A patient must choose a primary care physician from a list of providers. The relationship with the physician provided from the HMO is in a contract that is to deliver services to their patients for a fee. There can also be a group plan which is a HMOs contract with a group of physicians to deliver services. The HMO organization compared to PPOs, a PPO is a variation of an HMO, and it features traditional insurance and managed care.

HMOs are a type of MCO that requires a PCP and the patient can only see their PCP, no care is covered including specialist care if it is outside the network. These thing help keep cost down. HMOs have two sub groups, the staff model and the group model. The staff model were the HMO owns the health care facility and pays the providers a salary, all care under this plan must be done in network (all owned by the HMO). The group model In the HMO system has a contract with a health care facility and the facilities providers and there is an agreement that the providers in the network that will only see the HMO’s patients. Then, there is the open panel where in this system providers agree to be PCP providers for a HMO and can also see other patients. The network model is when there is an agreement with healthcare facilities to accept the insurance and see the patients. The final type of HMO plan is the Independent Physician Association (IPA), the provider is paid an agreed price for the services and they see a high number of patients. Now to look at the PPO plans, for these plans contracts are made with providers for them to provide care to the patients as a preferred provider in the network. The providers agree to see the patients at their own office and are paid the agreed upon price for their services. There is no PCP or

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 maintenance organizations. An organization that provides comprehensive health care to voluntarily enrolled individuals and families in a geographic area by member physicians with limited referral to outside specialists and that is financed by fixed periodic payments determined by advanced.