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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 include quality assurance, utilization management, and provider network management. Notably, the likelihood of managed care to enhance quality, accessibility, and plans of healthcare services depends on various factors.
In today's health care system, managed care plans exist in various types with the two common types being Health Maintenance Organizations and Preferred Provider Organizations. While most of the other types of managed care plans being hybrids of the two, individuals are required to know the details of their specific managed care…… [Read More]
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 health care settings, to defray costs (Buerhaus & Staiger 1996).
hat affect has manage care had on nursing education?
Surprisingly, the majority of nursing schools still do not work with a managed care organization or with physician training programs to facilitate educating student nurses in managed care competencies. However, 57% of hospitals do offer continuing education to staff members though educational seminars, staff meetings, and other programs (Copeland 2003, p.2-3). Although the managed care system is likely to change in…… [Read More]
• •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…… [Read More]
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 various types of accreditation processes that are used for healthcare practitioner and facilities in the United States. This is primarily because the specifics about the process and its subsequent procedures may differ based on the specific area within the health care field. In the managed care field, there are various organizations that accredit managed care in the United States such as
Joint Commission on Accreditation of Healthcare Organizations:
This organization is the quality oversight body for all healthcare…… [Read More]
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 the course of one year, health insurance premiums have increased by 14%. This is a part of a larger effort, to deal with rising costs at a variety of health care organizations. (Ableson, 2010)
As a result, a shift has occurred in the kinds of services that are being provided to consumers. This has lead to a transformation in the policies and procedures at managed care plans. To fully comprehend how these shifts are occurring requires examining: the…… [Read More]
Managed Care Organzations. (MCO)
Since the increasing costs of health care insurance became a significant issue in the profitability of health care provider in the 1980's health care provider, insurance companies, doctors and hospitals have searched for creative ways to cut costs while not sacrificing care qualitative. What has evolved in the health care industry is a shopping list of various organizations which offer health care services. The different organizations all address the issues within the health care industry with slightly different priorities. As a result, as a company, we have to determine which priorities are important to our group, and to our employees. We need to evaluate the levels of care, costs management, universal availability and quality of care which we are willing to pay for. The result of this process will be that the health care organization which is most appropriate for our organization will be fairly self…… [Read More]
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 state and federal governments are not providing enough support to public hospitals.
Nearly 18% of hospitals with Emergency Departments (1out of 5) were shut down, according to figures provided by the American Hospital Association.
2001 -- 4,045 hospitals in the United States have Emergency Departments, a drop of 863.
2002 -- Emory Parkway Medical Center, Atlanta, Georgia -- closed. Cause: After 28 years, excluded from participation in some managed care plans.
2002 -- St. Luke…… [Read More]
Doctors too are crippled and pressured by managed care organizations that tend to influence their decisions. Today, Managed care presents an unhealthy prospect and the future for such an unethical, unprofessional and profiteering approach is rather bleak. Under these circumstances of growing public remorse and rancour, it seems rightful for the government to intervene and set right an ailing system which threatens the very object of managed care: that of providing quality medical care. Thus, the future for managed care as it is today, is really bleak and a change is imminent and urgent. It is hoped that a single player system would finally be in place. The bill introduced by Cong. John Conyers, if successfully passed, will create a new positive wave in American medical history.
Tufts management care Institute, " a rief History of Managed Care," Accessed April 25th 2007, available at http://www.thci.org/downloads/riefHist.pdf
Kaiser Permanente, "In the…… [Read More]
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 rise of HMOs (health management organizations), as have the numbers of uninsured Americans unable to afford to buy health insurance. Many of these persons use the emergency room as their primary site of healthcare.
There is clear evidence that some Americans with high-quality health insurance are over-tested, despite the existence of HMOs. "Some research groups estimate that excessive, unnecessary testing and procedures account for as much as one-third of U.S. medical spending, which totaled more than $2 trillion in…… [Read More]
Likewise, the therapist in front of the mirror is expecting a credible "performance" that illuminates and furthers the therapeutic process (Johnson et al., 1997).
Solution-focused therapy encourages all participants to attend to their own wants and needs, not just those of their partners. Depending on the goal, therapists recommend that each participant take charge of caring for oneself as well as appreciating how his or her own actions influence others (Dermer et al., 1998).
Dermer et al. (19918) went further to express that solution-focused methods encourage clients to discuss ones desires and wishes at length but to do so in positive terms (such as through the "miracle question). Positive insights are encouraged, but negative insights are not. When clients complain and blame, the job of the therapist, is to redirect the conversation back toward searching for exceptions and use solution talk, rather than excluding insights, they selectively reinforced.
Solution-focused therapists'…… [Read More]
Managed Care Organizations: Basics of Negotiating and Contracting
Managed care organizations, and corporations generally, have legal departments or law firms that zealously represent their interests. Consequently, in the managed care environment, practitioners need to be legally savvy when it comes to negotiation and contracting. The focus of this work in writing will be the negotiating and contracting in the managed care setting.
Three Basic Elements of a Contract
The entire U.S. economy is based on "the freedom of individuals to contract and a system of law that enforces contracts freely entered into." (Oilek, 2011) A contract is defined as "a voluntary, deliberate and legally binding agreement between two or competent parties. Contracts are usually written but may be spoken or implied, and generally have to do with employment, sale or lease, or tenancy." (Business Directory, 2011) There are three very basic and very essential elements to a contract that is…… [Read More]
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…… [Read More]
Nursing Tasks, Methods, And Expectations
State of the Industry
The Art and Science of Nursing
Relative Pay Scales
Male Nursing Roles
The Influence of the Nationalized Healthcare Debate
Proposed Methods toward Recruiting Nurses
Joint Corporate Campaigns
Steps to Recruiting Men
Recent employment trends in the nursing field have demonstrated a disconcerting drop in the number of employed and employable nurses. In what has been traditionally a female dominated filed, the exit rate of both men and women, as well as the approaching retirement of a majority of existing nurses, threaten the long-term care quality of hospital and other in-patient care facilities.
This paper examines some of the factors behind the current nursing shortage, and offers suggestions as to how to reverse the trends which, if left unchecked, threaten our nation's health care delivery system.
Since the days of Florence Nightingale, patients in hospitals around the…… [Read More]
managed care has now permeated the general atmosphere of health care and the healing process in society. The purpose of this essay is to discuss the evolution of managed care and its practices and how they impact profession of health care and its subsidiaries. This essay will include personal opinion on these impacts and discuss how managed care in its current status is not aligned with many of my beliefs and values.
Evolution of Managed Care
The nature of modern managed care is very invasive and permeates deeply throughout society and law. Managed care spans a wide range of entities, organizations and influences. They are often heavily regulated, managed and studied. Managed care entities have grown and evolved significantly in the past decades. There are many reasons to why managed care as evolved in this manner and how these causes have materialized into effects that have placed many challenges in…… [Read More]
, income is quite often decreased and patient care sometimes adversely impacted due to time constraints, the need to hire a dedicated insurance person for the office, and the innumerable and sometimes counter-productive, forms and questions the HMOs ask of their medical professionals (See: Zimet, 1989, 2002).
The survey instruments were both quantitative and qualitative in nature, and included four to six sections: basic demographics; general information about the practice (theoretical orientation, hours worked, staffing, etc.); basic locus of stress and attitudes towards practice; financial aspects of the practice; and a burnout inventory (designed to identify factors contributing to job or field burnout). Sample sets were then cross-tabulated and the results presented in tabular form, along with a robust discussion.
One of the aspects of the research was to infer the evolution of the practice in relation to managed care parameters. As expected, the study found that managed care often…… [Read More]
Consequently, there is need to adopt various measures that could help in reducing or limiting increases in medical expenditures.
One of the ways that can lead to the reduction of health care expenses is by preventing illnesses. Statistics has clearly shown that in the United States, the causes of death have been grouped into different categories by laying down the exact causes instead of grouping them using the traditional oriented method. Lessening the risk of preventable illnesses is crucial for the reduction of medical costs because preventable diseases constitute approximately 70% of the burden of diseases and associated expenditures (Fries et. al., par, 8). Risking medical cost is another way that would limit the growth of medical expenditure whereby those with poor health habit are highly associated with greater illnesses and high humanity rate.
The intervention of self-management has provided guidelines that would assist a person whether to opt for…… [Read More]
These skills are vital for them to make an impact, considering the powerful relationship between leadership strength and influence. (...)
In Australia the following study has noted a change in skill mix may be necessary:
ising demand for health services, cost containment and shortages of nurses, midwives and other health workers were cited as the major catalyst for skill mix changes by ICN (2005d in ICN 2006). ICN (2004 in ICN 2006) noted that the evidence base in the area of skill mix was limited, but growing, with examples of studies that reported cost and quality improvements. (Fox-Young, 2007, p.17)
egarding education, these nurses should have been exposed to training even in the classroom the would make them better prepared for these circumstances by,...using real life case studies in the classroom and clinical set- tings This complex and progressive learning is a continuous process that occurs throughout one's (Feldman &…… [Read More]
care I receive is delivered in a managed care style. The options of going to different care providers are limited so as to keep costs low, and my insurance company takes care of giving me a list of options. The doctors are designated along with the healthcare facilities -- and this goes to make up the provider network.
Much of the care that I receive also focuses on preventive medicine, so I am always told to take precautions and adopt healthy habits that will keep me from becoming sick down the line. Quitting smoking is one example of preventive care, and so I have adopted this approach.
The pros of managed care are that there is more emphasis placed on reducing costs and it is a streamlined program that is designed to help everyone in the long-term. The con is that there is not as much freedom of choice about…… [Read More]
It seems that in today's technologically rich world with the abundance of resources available to mankind that our collective health should be in a much better state. Despite the massive amounts of money spent towards finding cures to man's ills, the chronic illnesses such as cancer and diabetes continue to grow and trouble the people of our society.
Managed care therefore must be investigated as a root cause of the failures of today's medical profession in an honest and frank manner if any true understanding of what is happening may occur. The purpose of this essay is to discuss how managed care has fallen desperately short in its aims to control medical costs, and in fact will be highlighted as a main cause for the problem itself.
The idea of profit for health care has caused serious conflicts of interest within the practice of modern medicine. The…… [Read More]
Integrated Patient Managed-Care Information System
Identifying a Cost-Effective Integrated Patient Managed-Care System for Concord Hospital: A Managed-Care White Paper
This white paper is provided in response to a request review integrated patient managed-care systems for possible implementation at Concord. Because there are a number of sophisticated applications specifically designed for such purposes today, each with its own attributes, it is important to select the software package that best suits Concord's needs and can accommodate future expansion. To this end, this white paper describes the MedicsElite system components such as registration, appointment scheduling, billing, medical records, and management reporting, including a discussion of how the proposed MedicsElite Medical Practice Management Software can benefit Concord in these areas.
Overview of MedicsElite Medical Practice Management Software.
A review of several software suites for the purposes of this analysis was conducted, including Advanced Data Systems's MedicsElite, MediPro's Lytec's MediNotes Charting Plus Electronic Medical ecords…… [Read More]
Health Care Quality Management as it Applies to Managed Care
In the current age of improved answerability for quality of care, every healthcare expert should be conversant in the theory and paraphernalia of quality management) Quality Management-QM is an all-embracing attitude that pervades the management infrastructure, rules and customs of an establishment. It characteristically comprises of five fundamental doctrines -- undivided attention on the customer/supplier relationships; a stress on functional and care systems and the avoidance of mistakes; the use of decision making by the help of data; the willing participation of leaders and empowerment of the workforce; and an importance on persistently enhancing achievement in every spheres. (Carefoote, 1998) Managed care systems have come to be an important type of health care supply and funding in the United States.
Earlier, managed care comprised of health maintenance organization -- HMOs. The meaning of a managed care system thereafter broadened to…… [Read More]
Future of Managed Care
Medical facilities have become much more important today than they were ever before. The complex diseases are treated by treatment methodologies and the equipment that were nonexistent a few decades ago. But these facilities have also increased in the cost of treatment. The medical facilities thus need to find ways in which a patient can be offered services without over-burdening him. The financial and economic situation of the country as well as the planet has pushed many people below the line of poverty but the health conditions of the population have generally decreased. Thus there is a need of incorporating procedures that do not compromise the quality of health care services while reducing the costs. This can be achieved if the triangular elements i.e. state, hospitals and the patients collaborate and understand the limitations of each other without exploiting the needs of others. The doctors should…… [Read More]
Ethics of Managed Healthcare
Healthcare policy has emerged as one of the most important issues in American politics and will continue to drive significant aspects of contemporary American public policy debates in the near future. That is because, on one hand, the United States has maintained a system of economic Social Security programs since the post-Depression era of the 1930s and government funded healthcare since the 1960s that reflect a fundamental ethical concern for the needs of the elderly, the indigent, and the most vulnerable segments of the population. On the other hand, the realities of contemporary managed healthcare could quite conceivably bankrupt the nation within the next generation if significant changes cannot be introduced to reduce costs, improve the quality of care, and eliminate waste and healthcare-system-caused human illness.
In the most general sense, the quality of care simply means that healthcare services are widely available, affordable, and as…… [Read More]
Hayes, E. (2007). Nurse Practitioners and Managed Care: Patient Satisfaction and Intention to Adhere to Nurse Practitioner Plan of Care. Journal of the American Academy of Nurse Practitioners. 19 (2): 418-26.
Personal Response: At the heart of healthcare as an institution is, of course, the need to care for the sick and the injured. However, in the contemporary model of healthcare, effective communication during a crisis is not only important, but also vital. Communication by healthcare professionals takes the concern and worry out of the situation; offers a quicker resolution, makes better control of information possible, earns the trust of the public and individual families; and keeps the flow of information consistent and accurate, thus averting potential external problems. This is particularly important in the managed care situation, and even more relevant when dealing with APN (Advanced Practice Nurses) and NP (Nurse Practitioners).
Increased levels of diversity and change management…… [Read More]
The red and swollen appearance could be an on-site reaction to the administered medication. A change of type of antibiotic medication may be necessary.
Question 5: Simon begins to complain of chest tightness he is beginning to get distressed what may be occurring and what interventions need to be undertaken.
An asthma attack partially brought on by the psychological stress of the surgery and being in the hospital, combined with the physical trauma is likely. Simon, physician permitting, should be allowed with assistance to treat his asthma in the usual fashion, after screening for potentially more serious conditions that can manifest in chest tightness, such as a cardiac condition.
Question 6: You notice that Simon has become disoriented and is complaining of a headache what may be occurring and what interventions need to be undertaken?
Signs and symptoms of a concussion, the result of head trauma, are not always immediately…… [Read More]
physicians agree that managed care is not doing the job it was originally created to do. Although reform efforts have not worked in the past, many doctors believe now is the time to revisit reform to combat the lack of health care access to a growing number of Americans, escalating costs, and deteriorating quality. This paper explores the evolution of managed care, and its problems and possible solutions from the viewpoint of two organizations representing the interests of physicians.
In 1993, President Clinton introduced a plan for regulated health care reform in response to escalating costs and the growing ranks of the uninsured. From 1970 until the time of the reform proposal, health care spending had increased from $74.4 billion to $752 billion annually. The Clinton proposal was met with huge opposition from the "medical industrial complex" comprised of insurance firms, pharmaceutical companies, hospital suppliers and medical device companies and…… [Read More]
Patient Satisfaction in Quality of Managed Care
Aspect to be compared
Gender and Patient
Satisfaction in Managed Care, etc.
Stakeholder Perceptions of Quality in Managed Care Plans
Two Steps to Enhance Managed Care Quality
Emily eisman, MS
Jacobs Institute of omen's Health
Carolyn M. Clancy, MD
Paul L. Grimaldi, Ph.D.
To determine what the differences are and what variables might affect women patients' perceptions of the quality of managed care
To find out what attributes three different health care stakeholders, physicians, employers and consumers, value most in determining their assessments of the quality of managed care health plans
To explain the ramifications of two developments in managed care: the new application form for MCOs to become Medicare risk contractors, and the National Committee for Quality Assurance plan to begin performance-based accreditation.
Determining what the differences between men's and women's perceptions of the quality of…… [Read More]
Cox, T. (2010). Legal and ethical implications of health care provider insurance risk assumption. JONAS Healthcare Law, Ethics and Regulation. 12(4):106-116.
How healthcare providers really feel about managed care and other forms of insurance is very important. If doctors and hospitals do not feel good about the payments they receive from specific managed care organizations, they may choose not to work with those organizations. That can leave a large number of patients without care in their local area that is included in their provider network - and that is not going to be beneficial to the growth of managed healthcare in the future.
Cox, T. (2006). Professional caregiver insurance risk: A brief primer for nurse executives and decisionmakers. Nurse Leader, 4(2): 48-51.
The different kinds of insurance offered for those who want or need medical coverage is very important. Managed care is part of that insurance landscape, but it is…… [Read More]
In addition the effect of bill has changed the documentation awarded through the state as of a certificate toward a license and authorizes a doctor to pass on duties to a PA with the purpose of managing physician's scope of performance however Another effect of bill has enabled Indiana's doctor assistants to widen their area of the health care services and also provided an innovative average of patient care (Stephanie, Matlock (27 April, 2007). Health care bills gives right to patient to know what health care should be known by the plan as well as several limits on care, kinds of health care be not enclosed, any treatment diagram required to endorse in advance. Yearly planning about on disburse to physician and health providers, file a complaint regarding any, disagreement between patient and the plan, and also procedure to make complaint, allowance to access emergency room twenty four hours a…… [Read More]
Today, however, the majority of practicing therapist use a method that is solution based. The issue is to find resolution for the immediate problem without trying to ascertain what happened in the patient's childhood and the years leading to the problem that caused it (Behavioral Health Services and Prevention (http://mentalhealth.samhsa.gov/publications/allpubs/SMA00-3437/SMA00-3437ch3.asp).
A solution based therapy can be completed in several sessions and the person also learns coping tools for identifying and changing problems that appear in the future.
This method is done by having patients come to therapy on an outpatient basis, thereby saving overhead costs as well as session costs.
In addition the three entities can work together toward preventative mental health care by identifying and reducing risk factors whenever possible.
isk factors and protective factors are also central to an understanding of prevention in the mental health and substance abuse arenas. The presence of risk factors is associated with…… [Read More]
The bulk of quality improvement measures are working for managed care by providing insight as to what can be done to improve care therefore reduce mortality rates, and maintain a high level of customer satisfaction which in turn helps to build the managed care health business.
Population Health Focus
Population health refers to the physical, social, cultural, and economic environment in which we work and live (adzyminski, 2006)."
This has become a focus of many managed health care organizations as they work to reduce the risks to their local consumers by way of stress, environmental factors and other elements that have a direct impact on the consumer health concerns.
The goal of population health is to maximize the health of any given population. In doing so it contains elements of program development, development/evaluation of health care policy, and program and systems evaluation. It uses an approach that concentrates on…… [Read More]
Health Insurance & Managed Care
There are four main types of managed care plans. First, it helps to have a basic understanding of what managed health care is. Managed care "combines healthcare delivery with the financing of services provided" (Green & owell, Chapter 3). In a typical managed health care system, the payer restricts the patient with respect to what facilities and doctors the patient can use. The facilities reduce their fees in exchange for the promise of substantially more business from the managed health care organization. Managed health care takes six distinct forms, according to Green and owell (2013, Chapter 3).
The first of these is the exclusive provider organization (EPO), which "provides benefits to subscribers who are required to receive services from network providers." In this model, the patient coordinates care within this network, with the primary care physician. Under this plan, the EPO coordinates the network of…… [Read More]
Care Coverage and Inequalities in the Education System
Traditional Care Coverage vs. Managed Care Coverage
Traditional care coverage is also known as Fee-for-service (FFS). Under this model, the patient pays for services that are itemized in the Invoice. The physicians gain an incentive to offer more treatments as payment depends on the quantity of care and not the quality of care. In the health insurance and healthcare sectors, traditional care coverage happens when physicians and other caregivers get a fee for each service like laboratory tests, office visit, procedure and other healthcare services. After providing services, the patient makes payments retrospectively. Traditional health coverage enables the patients to choose a healthcare provider, including a favorite hospital or doctor. The services rendered are paid for by the patient and then submits the bill to the insurance firm for reimbursement of the percentage it agreed to the insurer for the patient (Kongstvedt,…… [Read More]
"Studies of the relationship between managed care penetration in the health care market and expenditures for Medicare fee-for-service enrollees have demonstrated the existence of these types of spill over effects" (Bundorf et al., 2004).
Managed care organizations generate these types of spillover effects by increasing competition in the health care market, altering the arrangement of the health care delivery system, and altering physician practice patterns. Studies have found that higher levels of managed care infiltration are linked with lower rates of hospital cost inflation and lower physician fees are consistent with competitive effects. "Other studies demonstrate the impact of managed care on delivery system structure including hospital capacity, hospital admission patterns, the size and composition of the physician workforce and the adoption and use of medical equipment and technologies. More recent evidence has linked market-level managed care activity to the process, but not the outcomes of care" (Bundorf et al.,…… [Read More]
Managed Care Health eimbursement 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…… [Read More]
managed care be handled through private insurance providers.
Should managed care be handled through private insurance companies?
Should managed care be handled through private insurance companies?
Managed Care is defined as " a health care plan, such as health maintenance organization (HMO), that "manages or controls costs by monitoring how medical professionals treat patients, limiting referrals to expensive specialists and requiring preauthorization for hospital care and other services to hold costs down." ("Triggers, caps, mandates: decoding the health care debate," 1994.) Managed care is now offered by all types of health insurance providers. The term includes health maintenance organizations (HMOs) that combine insurance with direct delivery of care and the preferred provider organizations (PPOs) that offer discounted medical bills if certain providers are used. In some cases, In many states, Medicaid coverage is now provided through private managed care organizations that have contracts with the state. Thus people…… [Read More]
Medical Care Services
The current delivery of health care services represents one of the most important subjects for discussion both in the Obama Administration as well as the epublican one and the Administrations that preceded the Bush one. egardless of political color, it must be pointed out that the health care system in the United States does not only depend on the ideological orientation, but also on the people and their own beliefs in terms of human action and interaction. It is a clear fact that "Ten years ago, the U.S. healthcare system was declared "broken," and it has not improved. Fixes promised by managed care have not materialized. Premiums are rising. Hassles for patients and physicians abound. Nearly 45 million Americans are uninsured." (Garson, 2000)
One of the most severe problems facing the health care system in the United States is the discussion that is being held between those…… [Read More]
American Healthcare System has been at the center of debate for many years. One of the most pressing issues confronting the healthcare system is Medicare and its beneficiaries. The purpose of this discussion is to focus on the ramifications of moving Medicare beneficiaries into managed care organizations (MCOs). Our investigation will illustrate that moving the Medicare beneficiaries into MCOs are a bad idea because there will not to be any real cost savings and many individuals are likely to be denied needed care.
An article found in American Economic Review explains that Medicare is the second largest government entitlement program in the United States. The cost associated with running this program is astronomical. The article asserts that in 1999 the government spent $230 billion or 13% of its budget on Medicare and its beneficiaries. (Antos and Bilheimer)
The major issue with Medicare is that it is expected to…… [Read More]
Health Care Plans
Types of Health Insurance
This type of insurance is also known as a traditional or fee-for-service plan. The benefit of an indemnity plan is the flexibility; this plan allows members to choose any doctor or hospital. However, members must pay an annual deductible and then a percentage of each medical bill. Although these plans offer the greatest freedom to select any doctor, they are usually the most expensive option.
Typically, the member or the provider sends the bill to the insurance company. These plans usually have an annual deductible before the insurer starts paying. Once the deductible has been met most indemnity plans pay a percentage of what they consider the "Usual and Customary" charge for covered services. The insurer generally pays 80% of the Usual and Customary costs and the member is responsible the other 20%, known as coinsurance. If…… [Read More]
Provide sustained technical assistance (Expert Panel Meeting: Health Information Technology: Meeting Summary, 2003)
Evaluation of the process in rural and small communities includes: (1) scope of the project; (2) goals; (3) critical success factors; and (4) technical assistance." (Expert Panel Meeting: Health Information Technology: Meeting Summary, 2003) Community grants have been focused on the provision of 'personal digital assistant (PDA) systems in assisting with the decision support role. The initiative is stated to include: (1) development of toolkits; (2) leveraging known tools; (3) developing capacity; and (4) disseminating best practices. (Expert Panel Meeting: Health Information Technology: Meeting Summary, 2003)
Ormond, Wallin, and Goldenson report in the work entitled: "Supporting the Rural Health Care Safety Net" (2000) state: "The policy - and market-driven changes in the health care sector taking place across country are not confined to metropolitan areas. Rural communities are experiencing changes impelled by many of the same forces…… [Read More]
Some of the most pressing problems in the world today are global health care needs. There are so many different health issues facing the world, from HIV / AIDS to tuberculosis and malaria in many third-world countries. We can wipe out these diseases in modern times, but because of living conditions and limited resources, they continue to reappear and take lives. Education is one way to eliminate some of these issues, but nursing is another way to address and improve global health care needs. For example, many children die of malnutrition and dysentery every year, even in these modern times. Nurses in the field could not only assess these children and help them get the care they need, when they need it, they could educate families and other health care workers, as well. They could even help countries develop programs to address these issues, as well. They could help countries…… [Read More]
Healthcare: Clinical Integration
What is clinical integration
History of clinical integration
Goals of clinical integration
Importance of clinical integration
New payment models
Barriers to clinical integration
Lack of practitioner alignment
Lack of interoperability
How to achieve success in clinical integration
The future of health care systems
Physician acquisitions vs. clinical integration
HIEs -- solution to clinical integration?
Policy makers are beginning to appreciate the fact that only systemic change can effectively change, for the better, the manner of health care delivery in the U.S.; and that anything less would only alter the system's edges - with little or no substantial effect on cost-control, innovation-promotion, effectiveness of reward incentive schemes, coordination and coverage (AHA, 2010). Clinical integration has been found to be crucial to the change needed for the achievement of the aforementioned goals (AHA, 2010). Despite…… [Read More]
Toward that same end, the new strategic plan must also include provisions for a comprehensive centralized governance system.
The second most important reason that MUSC requires a new strategic plan relates to the impact of managed care, HMO insurance, and the healthcare crisis that accounts for many uninsured patients.. Evolving legislation delineating the respective funding responsibilities of federal and state government programs may place additional financial burden on healthcare institutions, particularly those that are engaged in providing education services, those that maintain research programs, and those that furnish medical services to a large proportion of patients who cannot afford to pay for their share of those services. Therefore, a comprehensive plan must allow for subsequent change within its formulation, because MUSC maintains educational programs and research programs, in addition to serving a large needy and/or uninsured constituency.
Finally, the new plan must address the formulation and integration of comprehensive communications…… [Read More]
Healthcare Financial Management
To quote Jonathan Clark at the beginning of his article, "Improving the revenue cycle can be a daunting task due to the scope and complexity of the interdepartmental process." Of the suggestions offered by the authors, which concept(s) give you the greatest insight into creating an improved evenue Cycle process in the organization where you work (or one in which you are familiar)? Be sure to identify which article or author you are referencing.
In his comprehensive advisory article to improve the medical industry's revenue capturing capabilities, entitled Strengthening the evenue Cycle: A 4-Step Method for Optimizing Payment, Jonathan Clark provides a series of sensible solutions to the ongoing dilemma of payment optimization. David Hammer also provides guidance to healthcare finance professional in his article The Next Generation of evenue Cycle Management, by reminding them that the key performance indicators (KPIs) which dictated policy in previous years…… [Read More]
health care to an indigent population.
As illustrated by the case, there were many unique problems associates with delivering health care to the indigent population. First, communication was an issue plaguing all parties involved. Difficulty in regards to understanding overall objectives and health care plans made operations inefficient and costly. Massive errors resulted from communication issues that ultimately hindered the access and quality of health care to the indigent population. Communication is the foundation of delivering health care. Everyone, from owners to employees must be able to effectively communicate in order to offer the quality of health care needed to support the indigent population. Without simple and comprehensive forms of communication, the overall health care program will falter as stakeholders are unaware of the overall vision and plan for the health care system.
Education also is a very profound problem in delivering health care to the indigent population. The community…… [Read More]
Evolution of Health Care Information Systems
The objective of this study is to compare and contrast a contemporary healthcare facility or physician's office health care facility or physician's office operation of 20 years ago and to identify at least two major events and technological advantages that influenced current HCIS practices. The physician's office and health care facility of 20 years ago was a paper-based operation. All records were paper records, appointments were written on calendars and prescriptions were handwritten, notations on the patient's health records was done by writing on the physical paper record and all hospital orders were written by hand. During the 1970s hospital growth and expansion occurred and the expenditures for Medicare and Medicaid were on the rise. At this time mainframes were still in use and microcomputers became available and not only were they smaller but they were also less expensive. However, transformation did not come…… [Read More]
Contracts with doctors often contain a clause which doesn't allow the doctors to discuss
Health care 7 with their patients financial incentives to deny treatment or about treatments not covered by the plan (Glazer, 1996). This has caused many consumers, especially those with chronic illnesses, to form organizations with the American Medical Association and physician specialty groups to promote legislation forbidding "gag rules" (Glazer, 1996). One group, Citizen Action, has 3 million members and "has been lobbying in state legislatures for laws that would require plans to disclose how they pay their doctors; give patients the right to choose specialists outside the plan; and provide appeals for patients who get turned down for expensive treatments" (Glazer, 1996).
The doctor-patient relationship is also affected if a patient must switch to a new doctor under managed care. Having a longterm relationship with a primary doctor is important because he or she is…… [Read More]
Healthcare in the United States: Where We Have Been, Where We Are Going
The current healthcare crisis in America is not one that happened over night. It is one that has been building for more than a quarter century. There was a time in America when healthcare was a stellar institution: research, cures, technological advances, and treatments. The focus of healthcare was maintaining and improving the quality of life. Then, during the early 1980s, managed care became an entity between the physician, the patient, and the healthcare provider of hospital services. It began subtly, but has, today, become one of the most aggressive and successful business ventures of our time; and it has been the unmaking of a once stellar and progressive American institution.
Managed care is a "distinctly American" product (Birenbaum, 1997). It was legislation introduced by the Nixon Administration with the intent to regulate healthcare and to maintain…… [Read More]
What direction is the quality of health care and delivery of health care moving in; it is not moving in a direction at all. Like the pendulum, the direction of health care remains suspended to the far side - right or left, depending upon which side of the political isle one is on. The pendulum remains frozen in time, and it reflects chaos in the delivery of health care and the quality of patient care. Health care remains the captive audience to managed care company stockholders and executives whose business focused decision making on what benefits can access, when, and where remain guided by an archaic DG system that was implemented more than twenty-five years ago.
If there is a direction for American health care access and quality of care, it is that direction of circling the drain before it falls into the black abyss of the unknown, and…… [Read More]
(ennie; Fontanarosa, 2006)
Apart from financial reasons, millions are not bale to access healthcare due to a lot of barriers inclusive of geography, racial differences and immigrant status. The people who do not have access to required care, that might comprise incapability to get primary care chronic care, specialist care, or emergency care stand at risk for severe health consequences. As per a recent report, absence of health insurance was linked with considerably lowered application of recommended healthcare services for cancer prevention, cardiovascular disease threat reduction, and diabetes management within the lower-income as also higher-income adults. Apart from the concerns, trouble, and stress directly associated to their illness, patients those who lack insurance or are underinsured also encounter increased levels of debt, threatening calls from collection agencies, anxiety, and possible insolvency. (ennie; Fontanarosa, 2006)
Impact of reform measures on the nursing profession:
The U.S. healthcare system is considered among the…… [Read More]
Day treatment programs can provide services at less cost because the patient goes home at night after being treated during the day, which often is used for rehabilitating chronically ill patients (Sharfstein, Stoline, & Koran, 1995, p. 249). The mere fact of having more choice benefits some patients by giving them more say in their care.
Patient-focused care involves a method for containing in-patient costs for hospitals and for improving quality by "restructuring services so that more of them take place on nursing units rather than in specialized units in other hospital locations, and by cross-training staff on the nursing units so that they can do several 'jobs' for the same small group of patients rather then one 'job' for a large number of patients" (Kovner, 1995, p. 186). Kovner notes a number of barriers to this type of care. One reason has been that hospitals have not had to…… [Read More]
Within some managed care systems, physicians who perform more procedures and spend more time with patients than is deemed necessary are penalized or physicians are simply paid based upon their number of patients, rather than the extent of the care they give to patients (Jecker 1998).
Managed care was designed to reduce the tendency of physicians to please patients with 'good' health insurance by allowing them to take drugs (such as brand-name medications or antibiotics) when they were not strictly necessary or have tests for which there was little indication that they would be beneficial for the patient. One of the most controversial aspects of managed care was the insistence that patients obtain referrals for specialists and the need to remain 'in network' for treatments. This was despite the fact that medical opinion might vary widely in terms of the best way to treat an illness. A patient with cancer…… [Read More]
NPV and IBN
Net present value analysis can be used with respect to IBN in a real life investment situation where healthcare organizations are looking to decide where to invest revenues or capital for future expenditures. It may help healthcare organizations calculate the value of cash flows within the organization over varying time periods. Net present value analysis allows organizations to consider the difference in future cash flow values compared with the cost of raising capital for future investments. Organizations can use this analysis to decide whether or not to incorporate certain expenses into IBN.
A healthcare organization can use net present value analysis for example to pick between varying investment projects for example. A hospital could for example decide whether to invest more of its resources in improved technology and security measures or whether to invest more resources in research geared to finding new treatments for cancer patients that…… [Read More]
Strategic Management of a Healthcare Facility in St. Louis
In the late 1800's and early 1900's St. Louis was a major center for automotive and other heavy manufacturing but the industrial restructuring of the Midwest during the latter half of the century has resulted in consistent economic decline of the St. Louis region. Today however as the rest of the country faces a slowing economy this region is showing new signs of growth. [Kotkin, 2002] Due to changing socio-demographics, the demand for health care and advanced medical technologies is growing consistently with a concomitant rise in health expenditure. [Zhou 2001] Health expenditure in the U.S. has risen from 7.4% of the GNP in 1970 to 15% of the GNP in 1995.[Zhou, 2001] The Health care sector deals with not only the clinical medical services, but also include methods which finance them, for e.g. insurance, benefit schemes, Medicare and Medicaid. eforms…… [Read More]
Shuttling the results from an outside provider, because the health insurance agency will only reimburse outside screening, forces the patient to wait and possibly incurs more costs, if the delays in obtaining diagnostic information worsen the patient's condition. This can ultimately result in more prolonged treatment. Many patients may also be put at risk because of the logistics of being transported to outpatient facilities for essential screening and rehabilitative services, while they are still convalescing.
Being able to conduct all necessary tests in-house results in great efficiency, swifter screening, and improves coordination between the different providers involved in the case. Our hospital has extensive resources for patients, and can provide a wide range of treatment options, particularly in its specializations of cardiac and orthopedic care. And improvements in technology that are keeping extremely sick patients alive for longer periods of time also mean that, quite often, patients require attention from…… [Read More]
Security in Healthcare
The recent advances in technology -- databases that store personal medical records and information -- are bringing tools to patients, doctors and other healthcare professionals that were simply not available just a few years ago. There is hope that eventually, a doctor in Hawaii that is treating a medical emergency for a tourist from Florida, will be able to access the digitally kept medical and healthcare records for that injured tourist. In other words, there will likely be in the foreseeable future a national database -- that perhaps links state databases with each other the way the FBI and local law enforcement agencies are linked -- that will be of enormous benefit to citizens and their healthcare providers.
But before that nationally linked database can become a reality, there are a number of potential problems that need to be ironed out. For example, legislation needs to be…… [Read More]
Managed care and utilization review (U) play an integral part in patient care and reimbursement (Mahmoud, E and ice, G, 1998). Scott echoes it experts Brian P. Bloomfield, od Coombs, David Knights, and Dale Littler (2000), who say:
IT system enjoys what one might call a special relationship with esource Management. Its role as depicted in the review is one centred on the improvements and furtherance of a 'balanced' dialogue between doctors and managers. A corollary of this is that it must be neutral politically speaking (see Bloomfield 1995). Thus the review authorizes the introduction of the new it system by subordinating it to the cause of dialogue between doctors and managers. The review represents the information requirements of hospital doctors and management and thereby portrays the it system as fulfilling a preexisting need. The narrative structure here is founded on the discovery of a state of readiness on the…… [Read More]
A healthare organization audit summary
Legay Emanuel Medial Center, at 2801 North Gantenbein Avenue, Portland, Oregon is
is an IRS 501 ( ) 3 not-for-profit, tax-exempt orporation omprised of five full-servie hospitals and a hildren's hospital. The Center's award-winning failities offer an integrated network of health are servies: aute and ritial are, inpatient and outpatient treatment, ommunity health eduation and a variety of speialty servies.
The area's largest loally owned, nonprofit health system, Legay Health's is a lead healthare institution in the region, ommitted to omprehensive servie provision to lients through a network of healthare providers toward a healthier and wellness ommunity. Projeted growth for the institution under the diretion of the Offie of Development advanes the mission and vision of Emanuel Medial Center, dediated to legay of good health for 'Our people, Our patients, Our ommunities, Our world' through development of sustainable programs that generate private support…… [Read More]
Universal healthcare is the only saving formula for this nation, which is doomed in a health care crisis of unprecedented proportions. There is a urgent need to transform healthcare from its present state of commercialism towards the humanitarian approach which guarantees 'healthcare for all' independent of their social or financial circumstances. A shared and collective responsibility of healthcare management is the only viable formula for America. It is high time we learn from Canada, UK and other European nations and restructure the current broken state of our healthcare. The successful passing of the USNHC act (H.R. 676) is the only way for America to wake up from its healthcare nightmare. Will the powerful insurance industry hold its ground yet again and resist this awakening leaving all the citizens doomed? This is an important question for all the citizens of our country.
1) Science Daily, 'American Values lamed for U.S.…… [Read More]
This is necessary to provide a seamless platform on which health solutions can be effectively integrated and deployed. Without using such a platform, the development of electronic health care facilities will be more difficult to deploy. In other words, Tele-health is part of the overall healthcare ICT (Information Communications Technology) solutions that enables healthcare to be pushed out to the edge, for local delivery, and to be more evenly, efficiently and effectively distributed.
Broadband communication is the underlying technology of choice when discussing electronic applications. It is certainly important for inter-healthcare provider communications delivering sufficient bandwidth capacity between sites. The delivery of home care electronic should not rely on the broadband technology is not universally accessible, particularly in rural and remote areas, and it can also be prohibitively expensive. Some broadband technologies can be delivered to remote locations, such as satellite-based technology, but this is impractical and too costly to…… [Read More]