Note: Sample below may appear distorted but all corresponding word document files contain proper formattingExcerpt from Term Paper:
managed care in modern health care. Specifically it will include a brief history of managed care, along with some pros and cons about the process.
Managed care is an arrangement where an insuring organization accepts the risk for providing a defined set of health services, using a defined set of providers, for a defined population, in return for a fixed or regular per capita payment" (Lammers and Geist, 1997, p. 46). Briefly, for managed care to survive and prosper, member physicians must do the minimum health care necessary to keep the patient healthy and still turn a profit.
Managed care is not a new phenomenon in health care. In fact, it has existed in the United States since the 1920s. "Historians cite the 1930s as the beginning of managed care as we know it today. The launch of the Kaiser Health Plan during World War II resulted in the first clinic-based system of managed care" (Editors). Edgar Kaiser, the founder of the Kaiser Health Plan (still one of the largest and most successful managed care plans), created an American phenomenon. Managed care is strictly an American invention, and still proves most popular in the United States.
After World War II, work was plentiful, life was good, and employers offered their employees great health care benefits, often 100% paid by the employer. By the 1960s, the introduction of government plans such as Medicare and Medicaid caused health care costs to skyrocket. By the 1970s, costs rose even more, approaching 14% of Gross National Product (GNP). The decade from 1985 to 1995 saw the proliferation of HMOs and PPOs in an effort to curb escalating costs. Today, MCOs [Managed Care Organizations] cover three out of four American workers, and annual inflation in health care costs has been reduced significantly" (Editors).
Between 1940 and the 1970s, more employees were covered by health care insurance than ever before in the history of the country, contributing to better health care, but also contributing to the steadily rising health care costs.
When employers did not provide group coverage, many middle-class Americans could not afford an individual insurance policy for their families; some did not have access to group coverage because they were self-employed, small entrepreneurs with limited incomes; and there were people with long-term serious preexisting conditions who were denied coverage through employment, or who simply could not afford the extremely expensive risk-adjusted policies available in the marketplace (Birenbaum, 1997, p. ix).
By the 1980s, managed care and HMOs were beginning to explode. "The Tax Equity and Fiscal Responsibility Act of 1982 expanded the market by making it easier for Medicare and Medicaid beneficiaries to enroll in HMOs" (Birenbaum, 1997, p. 17). Managed care was often the most popular choice for employer provided insurance because of its affordability and convenience. In the 1990s, managed care has come under scrutiny, but continues in popularity and convenience.
Managed care replaces the traditional doctor patient relationship with a 3-part relationship, adding the MCO to the mixture. Instead of one doctor, the plan participant may have several specialists who must all be referred by the participant's primary care physician. "Under these drastically new circumstances, providers, including individual physicians and nurses, as well as organizations like hospitals and clinics, have profoundly altered their behaviors" (Lammers and Geist, 1997, p. 46).
Doctors are no longer responsible for one patient at a time. Their practices have become glutted with thousands of patients who must all be dealt with as quickly and efficiently as possible. Patients are no longer simply patients; they have become consumers because they can pick and choose their health plans almost as easily as they can choose oranges at the supermarket.
Several important issues face managed health care, both positive and negative. Initially, managed care served a major purpose in American health care. At its inception, many experts believed it would revolutionize health care. Because of relatively low premiums and low-cost "co-payments" for patients, health care would become more affordable for everyone. Attending physicians would quickly and easily refer patients who needed to see specialists. Physicians could see more patients, and patients would save money on their health care.
What produces value in managed care is a good health outcome rather than medical intervention. Not every visit to a doctor is necessary; nor is every test conducted, every medication prescribed, or every placement in an intensive care unit going to produce an effective outcome (Birenbaum, 1997, p. 14).
Many of these expectations actually occurred. Managed care is one of the most widely used forms of health care today. Because numerous companies are now in the managed care business, there is more competition among venders, helping to keep prices down and quality up.
However, there is also a downside to the managed care industry. Most doctors are no longer responsible for their own practice; they are employees of the managed care group. They are paid a salary and offered incentives and penalties according to their "numbers." Some physicians belong to several groups at the same time, and see patients from any or all of these groups. Either way, the physician is responsible for seeing as many patients as possible to generate the maximum fees. They may be penalized if they do not see enough patients, or they refer too many patients to specialists.
Health insurance plans divide up their revenues -- the premiums -- into funds for different kinds of services. In addition to a fund for primary care doctors' pay, there might be funds for specialists' fees, prescription drugs, emergency room visits, and ancillary services such as physical therapy, laboratory tests, and X-ray and other imaging studies (Stone, 1998, p. 173).
Clearly, the patient is last in line in this scenario. Managed care has turned health care into what many people call "factories." If a physician is behind schedule, he may not allot enough time to each patient. A patient may not obtain a referral if the physician feels there have already been too many referrals during the period. The patient is probably not aware of any of these restrictions, but they certainly have the feeling they are not receiving definitive health care.
Where individual physicians were once encouraged to do more for the patient, they are now "incentivized" to do less. Where providers once were responsible for curing disease, they are now increasingly concerned with health promotion and disease prevention, and with efforts toward excluding diseases from their lists of "covered services" (Lammers and Geist, 1997. p. 46).
Ultimately, managed care has turned the doctor into a businessman first, and a physician second. This is one of the major negative effects of managed care; it alters medical care at its very roots. "In the late twentieth century, the doctor has been reconceived as an entrepreneur who is now in the business of insuring patients as well as caring for them" (Stone, 1998, p. 161). This major alteration in the traditional doctor-patient relationship is probably one of the most startling and disturbing issues managed care must address. When a doctor stops being a trusted healer and becomes an accountant, the trust in the relationship is sorely tested. Because of this shift in trust, many patients no longer trust their doctor, or his expertise. "Second opinions" in medical diagnosis have become commonplace. Switching doctors is also very common - something that did not happen when the "family" physician knew and treated the entire family.
The ultimate question is whether health care is a social good or a market commodity. If you believe health care is a commodity like food or automobiles or clothes, then that leads you down one road. If it's a social good like public health or clean air, you go down another. -- John C. AARP Rother, (Wines and Pear, 1996) (Birenbaum, 1997, p. 159).
In another disturbing trend, managed care providers often try to "second guess" the physician, denying coverage or payment for certain "unnecessary" items. The patient is the pawn in these decisions, rarely understanding the denial or how to question the decision. For example, "Just before the sixth session, Dr. Jackson is contacted by a reviewer for the managed care health insurance program covering Lee's therapy. The reviewer informs Dr. Jackson that the company will not authorize payment for further psychotherapeutic care" (Cummingse, 1992, p. 215). Unfortunately, these situations are far too common, and the final victim is the patient who does not receive necessary care.
Many Americans are becoming increasingly dissatisfied with their managed care options. Some are returning to traditional insurance plans, hoping for a more personal relationship with a physician who is not tied to an HMO or other managed care organization. Some are opting for HMO plans that give them more choice over physicians and specialists.
In almost all surveys that compare HMO members with individuals who have old-fashioned health insurance coverage, the HMO members are less satisfied. In addition, consumers in "gatekeeper" free preferred provider organizations (PPOs) also are more satisfied than HMO members, mainly because their network…[continue]
"Managed Care" (2002, October 30) Retrieved December 5, 2016, from http://www.paperdue.com/essay/managed-care-137651
"Managed Care" 30 October 2002. Web.5 December. 2016. <http://www.paperdue.com/essay/managed-care-137651>
"Managed Care", 30 October 2002, Accessed.5 December. 2016, http://www.paperdue.com/essay/managed-care-137651
Managed Care is an approach or system of health care that manages the use of healthcare services, controls their costs, and evaluates the performance of healthcare providers. It is also considered as an approach to funding and providing healthcare services which focuses on controlling costs and enhancing the quality of care through several methods. Some of these methods that are used in managed care to help accomplish the described objectives
D.). Accreditation is basically important for various functions such as promoting the quality of healthcare delivered to consumers and other purchasers of care. Secondly, the accreditation is important because it helps health care organizations and facilities to recruit and retain qualified practitioners. This in turn enhances organizational efficiencies to lessen costs, identify means for enhancing service delivery, and lessening liability insurance premiums. Organizations that Accredit Managed Care Organizations in America: There are
Managed Care Timeline Luke Medical Center, Pasadena, California - established The change in hospital concentration in 68 large metropolitan statistical areas (MSAs) between 1981 and 1994 is positively correlated with the level of managed care concentration in 1993/1994. Congress enacted the Emergency Medical Treatment & Labor Act (EMTALA) to ensure public access to emergency services regardless of patients' ability to pay. 4,908 hospitals in the United States have Emergency Departments. Crowded emergency departments arise because
Managed Care One issue that has received a great deal of attention in recent months during the healthcare debate is the role of health insurance companies. Managed care was originally intended to lower costs within the American healthcare system to prevent overconsumption of health services that were unnecessary or of unproven value. However, the overall costs of the American healthcare system have increased rather than decreased in recent years, despite the
The reluctance to refer patients to specialists may also mean that nurses must practice more holistic, rather than specialized forms, of nursing. The desire for cost containment has resulted in many nurses assuming physician's duties, such as those duties confined in previous eras to the patient's primary care physician. In states with high HMO (Health Maintenance Organization) enrollment, more nurses were shifted to lower-paying nonhospital settings, such as in home
• •the marketplace lacks competition. Thus the consumer may have limited choice, and some sellers or manufacturers may not care if the consumer is dissatisfied. (Zelman, 1999, pp. 5-6) Managed care, then becomes an institution that is highly in need of regulation, according to those who make such decisions, as the need to be a consumer advocate (including those who are profiting from health care) has always driven the government to
Managed Care Plans Analyze how the policies and practices related to Managed Care Plans can influence the activities of managers in health services organizations. Over the last several years, the role of health care organizations has been continually evolving. Part of the reason for this, is because costs have been rising exponentially. Evidence of this can be seen with a survey that was conducted by the Kaiser Foundation. They determined that over