Managed Care

Managed Care

Summarize the history of when, how, and why managed care was developed.

The history of managed care in the U.S. dates back to the late 19^th century and early 20^th century, whereby the country implemented two health payment plans-a plan that required patients to pay service providers and a capitated plan. According to Kongstvedt (2013), the first excellent example of managed care in the U.S. involved Blue Shield Health Insurance Company and Blue Cross hospital care, which both had prepaid plans in 1929 with Baylor Hospital. These arrangements were later spread to other hospitals and were converted from nonprofits to for-profit institutions. In particular, reports indicate that Dr. Paul Ellwood Jr. was the first professional come politician to coin the termed managed care. He was pivotal in controlling costs and promoting health by converting no-profit healthcare services to prepaid, for-profit services.

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Define and discuss each type of managed care organization (MCO)—health maintenance organization (HMO), preferred provider organization (PPO), and point of sale (POS).

In the U.S., there are three major types of managed care organizations. The first is the health maintenance organization (HMO), a healthcare insurance organization offering medical coverage at a constant or fixed yearly fee. This type of care plan allows users to only pay for care offered within the network. Clients also choose their primary care doctor to handle most of their healthcare needs. The second category is the Preferred Provider Organization (PPO), a plan wherein health facilities and professionals render services at a reduced rate to only their subscribers. In this arrangement, users are usually charged more if they find their preferred care within the network. The arrangement often remains even if the client goes outside the network. The last managed care category is a Point of Sale (POS) arrangement. POS combines PPO and HMO by providing more limited choices to clients at reduced medical costs. Under this arrangement, clients can choose between HMO and PPO anytime they require care.

Explain the positive and negative aspects of managed care organization from the provider’s point of view—a physician and a healthcare facility—and from a patient’s point of view.

For physicians or healthcare providers, managed care has the advantage of reduced roles because they are assigned to specific clients. It also presents an opportunity for specialization because physicians only provide specific care for particular clients. The disadvantage is that managed care offers physicians or doctors minimal incentive because clients in a particular network pay fixed amounts. Sometimes, certain physicians with a good reputation may be overworked, while others (especially those new in the network) might receive fewer clients. This is because subscribers are the ones with the responsibility of selecting their preferred physician or care provider. For the patients, the advantage of managed care is the ability to reduce the cost. Patients often receive accredited and approved care because most managed care organizations only employ qualified and highly-skilled professionals. On the other hand, the downside is doctor restrictions for patients and the absence of specialty care. There is also the chance of patients receiving unapproved care.

Explain the three types of incentives for providers for efficiency in the delivery of healthcare services. Explain who bears the financial risk—the provider, the patient, or the managed care organization.

Unquestionably, incentives can assist providers in increasing their efficiency, commitment, and effort. They may include non-monetary and monetary incentives, which might be applied to individual providers, consumers, and institutions. For example, insurance companies can incentivize their physicians and healthcare providers by implementing pay-for-performance, discounts on insurance premiums, and annual bonuses (Abduljawad & Al-Assaf, 2011).

Offer your recommendations to accept or decline patients considering managed care health plans, with your rationale for each.

I would advise that patients accept managed care arrangements for several reasons. Most importantly, it can generally lower the cost of health without compromising the quality of care you will receive. If you manage to keep your network, there is a higher chance that you will receive appropriate care at a reduced rate. Besides enjoying a particular guarantee of care stipulated in your network, it is also easier to obtain prescription management.

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References

Abduljawad, A., & Al-Assaf, A. F. (2011). Incentives For Better Performance In Health Care. Sultan Qaboos University Medical Journal, 11(2), 201-206.

Kimuyu, P. (2018). The Role Of Managed Care Organizations Within The Healthcare Industry. GRIN, https://www.grin.com/document/388764

Kongstvedt, P. R. (2013). A History of Managed Health Care and Health Insurance in the United States. Essentials Of Managed Health Care. Burlington, MA: Jones and Bartlett Learning.

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Managed Care

In the United States, managed care is becoming an increasingly popular method of administering healthcare. It influences the clinical behavior of providers, as it combines the payment and delivery of healthcare into a single system, the purpose of which is to control the cost, quality, and access of healthcare services for a single bracket of health plan enrollees (Scutchfield, Lee, & Patton, 1997).

Yet, managed care often evokes strong or negative reactions from healthcare providers because they are paid a fixed amount for treating their patients, regardless of the actual cost, which may influence their efficiency level. This can challenge the relationships between doctors and patients (Claxton, Rae, Panchal, Damico, & Lundy, 2012; Sekhri, 2000).

Research managed care’s inception and studied some examples. Be sure to investigate the perspectives about managed care from the vantage of healthcare providers and patients. You can use the following keywords for your research—United States managed care, history of managed care, and managed care timeline.

Based on your research, answer the following questions:

• Summarize the history of when, how, and why managed care was developed.
• Define and discuss each type of managed care organization (MCO)—health maintenance organization (HMO), preferred provider organization (PPO), and point of sale (POS).
• Explain the positive and negative aspects of managed care organization from the provider’s point of view—a physician and a healthcare facility—and from a patient’s point of view.
• Explain the three types of incentives for providers for efficiency in the delivery of healthcare services. Explain who bears the financial risk—the provider, the patient, or the managed care organization.
• Offer your recommendations to accept or decline, for patients considering managed care health plans, with your rationale for each.