Health Care Infrastructure

¶ … Managed Care Health Reimbursement Systems in the United States With health care costs skyrocketing consumers and health insurance companies alike are seeking solutions to the growing crisis in health care within the United States. This crisis revolves primarily around the lack of coverage that exists for millions of Americans. Employers are more and more dropping out of traditional health insurance programs and seeking new ways to provide employees with health care services.

In response to the climbing costs of health care many reimbursement and health care cost containment programs are being developed. There are many health care reimbursement programs available to patients that provide some form of medical care cost containment and coverage. Among the most popular of these or at least the fastest growing are managed care reimbursement programs. Managed care reimbursement programs are becoming more the norm rather than the exception to the rule. Managed care programs have changed the face of health care in the United States.

Some have argued for the better whereas others for the worse. The managed care reimbursement system and its impacts on the medical community and patients is described below. Managed Care Organizations: An Analysis With the rising cost of medical care many health insurance agencies in the United States are tightening their belts. More and more health care reimbursement is an economic and social concern, particularly when more than 39 million Americans lack any form of health insurance (Kabalka & Rocha, 1999; Hanson, 1994).

Managed health care reimbursement plans have emerged as a way to help manage the current crisis that exists with regard to rising health care costs. The managed care approach or managed care organizations (MCOs) work by managing costs by imposing restrictions on health care services. Generally MCOs require that participants select a primary care physician group to facilitate and manage all medical care. They establish very stringent guidelines for treating patients, prescribing medications and utilizing services (Dranove, 2000).

The goal of most managed care reimbursement programs is reasonable and conservative service to patients. MCO's content that it is possible to minimize costs but still provide optimal health care services to consumers. In times of old patients relied on physicians who worked autonomously to manage their care; they receive complex care from hospitals independent of group plans and insurers generally did not intervene in determining reimbursement policies (Dranove, 2000). This has changed however as health care costs have skyrocketed.

Generally independent benefit consultants help employers make choices about what managed care organization to decide on (Dranove, 2000). Employers generally choose a single plan or possibly two plans for employees to choose from. Most people that are not working for a corporate organization find themselves at a loss when it comes to health insurance. Health care providers are generally reimbursed for services differently than traditional insurance plans under a managed care program.

Generally managed care may be considered a health care reimbursement system where third party payers control the costs associated with health care (Camperell & Mitchell, 1995). These third party payers advise physicians regarding health care costs. Physicians who participate in managed care programs generally share part of the financial risks for patients use of services, thus they are much more conservative in their treatment protocols (Camperell & Mitchell, 1995).

Primary care physicians that operate under managed care contracts generally work as gatekeepers; this means they generally monitor who gets access to what hospital services and act as referral agents for sending patients to specialty services rather than patients acting as their own gatekeepers and freely selecting which services to partake of or not (Camperell & Mitchell, 1995). If a patient does not access care through their primary care physician it is possible that they will be denied coverage for services rendered.

Managed care organizations require that physicians help manage the business of health care (Camperell & Mitchell, 1995). They draw up contracts with physicians that set certain terms for the number of expenses to be incurred and generally when expenses exceed this the physician or group is responsible for some portion of the deficit. Primary care physicians that work under a managed care program will receive payment for services whether or not they provide services to actual enrollees (Camperell & Mitchell, 1995).

Accountants working as third party agents in the managed care system generally keep track of the number of enrollees (Patients) seen by the physician each months, and the number of claims made or average number of claims per patient (Camperell & Mitchell, 1995). Generally economists predict that the trend toward utilization of managed care services will grow because at best it is a means to help control health care costs and provide health insurance to a greater number of people over the long-term.

The managed care movement is growing as some state "by leaps and bounds" and has impacted the medical profession as a whole as well as patients in many ways (Barron, 1997). It is important to note that physicians working under the managed care system are no longer to work as independent contractors managing medical care for patients and hospitals (Barron, 1997).

Rather now due to the fact in part that physicians income is coming from third party payers such as insurance companies, physicians are operating more under a for profit system where money becomes the primary issue at times rather than the patient. Commentary Managed Care Are managed care programs beneficial? There are many people that despise managed care organization and fight against their existence. Many people have a negative view of managed care services.

Most patients and consumers fear that managed care organizations promote the use of substandard health care policies. Others generally do not like the idea of not working through an independent physician. People who grew up in an era where they were free to utilize medical services in any manner they choose are generally turned off by the idea of a managed care program. There are several legal steps being taken however to assuage patient fears regarding malpractice and inadequate care.

Laws are being created that protect patients from inadequate care resulting from managed care practices, helping to reduce some of the fear and distrust associated with use of a managed care system (Cauchi, 2001). Generally practitioners are also working to help patients feel as though they are still getting the preferential treatment they deserve and working to make patients feel like people rather than numbers. Despite any expressed distrust of managed care systems, the number of patients enrolling in managed care programs grew to.