Managed care systems and organizational structures

Managed Care

The situation of health care in the United States has been according to many experts at a near disastrous level for many years. The concerns are many, one of which is that the for-profit system in health care has created a system where profit rather than care and quality drive the system and the care of patients. The more tests a physician orders the more cost the patient incurs and the more money the institution makes, leaving patients with insurance feeling as if they have been over-served and under cared for. Additionally, their insurance companies feel taken advantage of and over taxed, leaving them no choice but to raise premiums. With premiums high consumers and employers are left with fewer choices and cost-prohibitive choices. This has resulted in millions of people, many of who are children without coverage of any kind and those people seek routine medical care in hospital ERs, during perceived emergencies, accruing bills they are unable to pay thus causing for profit hospitals to increase prices as well, and the system now reaching full circle has hurt everyone in the process.

Zelman & Berenson, 1998, p. xv) (Birenbaum, 1997, p. 14)

Ideally, medicine should be ruled by rationality and efficiency in the choice and implementation of evaluations and treatments. This means that the variability between providers not only should be but can be eliminated, and the only factors that should make a difference in deciding who to treat and what treatment to undertake is the nature of the patient's disease or injury. Behind this kind of thinking is a very powerful guideline: we as a country or a planet cannot treat everything, and we need to make distinctions between treatments on the basis of effectiveness and cost. Managed care introduces explicit rationing, based on looking at an array of variables that can influence outcomes. (Birenbaum, 1997, p. 14)

In this climate a new system emerges, called managed care, again with the intention of profit, but with a differing approach. The managed care system, attempts to profit by providing less care, through limiting the services patients can have and creating insular systems of care that above all keep costs down. There have been many bugs to work out and consumers have again bore the brunt of the changes as for many years in its infancy the infrastructure was not quick enough to allow patients the level of care they needed in certain situations and trust in the greater community, as well as the government and the historically well voiced medical community consisting of doctors who see payments decline and regulations increase and fear personal loss.

Zelman & Berenson, 1998, p. xv)

Managed care has come under increasing fire, as government controlled managed care has waned in political and consumer circles. The private health care industries, answer to a failed bid for government provided care was private for profit managed care systems, and their early failures and differences have created consumer fear of the entire system. (Zelman & Berenson, 1998, p. 1) the response has been the lobbying of government to regulate managed care, a situation that some would say comes to little to late for the current state of health care, as the private (non-managed) health care system has been sorely in need of regulations for generations.

Government-inspired consumer protection efforts are most likely to emerge when one or more of several conditions exist: 1• •Consumers have particular difficulty in assessing the value of products or services.... •the costs of a bad decision are very high. This may happen either because the product is expensive or because the damage resulting from product failure or inadequate service may be considerable or even irreparable.• •the product is such that the consumer is locked in or unable to switch easily to another brand.• •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 act.

Lastly, the manner in which the managed care system has changed the way that sellers, in this case doctors, most of home have historically been in private practice, with clinical privileges to practice care in most of the local hospitals where they work. Doctors who have been in practice for years are seeking change and regulation within the managed care system, as many are reluctant to center their new lives around a salary and a job (as they were always self-employed in the past) where the intention of the dictated system is to reduce the amount of care, a reversal of historical precedence. The doctor and the patient are no longer allies in the fight against disease or toward health, now a perceived big brother makes many of the decisions. (Pauly & Berger, 1999, p. 71) the immediate result has been many individual physicians retiring early in the wake of many problems, prior to the managed care movement and after. The managed care system then relies to a great degree on new doctors or doctors who are actually relieved at the idea of losing a little autonomy to gain the benefits of a little protection, through employment.