Managed Care Research Paper

Managed care dominates health care in the United States. It is any health care delivery system that combines the functions of health insurance and the actual delivery of care, where costs and utilization of services are controlled by methods such as gatekeeping, case management, and utilization review. Different types of managed care plans came into development by three major factors. These factors include choice of providers, different ways of arranging the delivery of services, and payment and risk sharing. Types of managed care organizations include Health Maintenance Organizations (HMOs) which consist of five common models that differ according to how the HMO is related to the participating physicians, Preferred Provider Organizations

There has been discussion to have universal healthcare system similar to Medicare as a method to have a centralized monitoring system of cost. There have also been other systems tried beginning with HMOs in the 1970s in an effort to streamline access to necessary healthcare services by employing a gatekeeper to their access at the primary care levels. With patient dissatisfaction, PPOs were tried which circumvent the necessity of referrals (Hacker, 1998). Either of these models had substantial effect on healthcare outcomes while the cost of healthcare continued to skyrocket. The US spends more than any other country on healthcare but outcomes are not better (Blackstone, 2016). In 2010, under President Obama’s leadership, Affordable Care Act was passed and one of the promising features is the formation of accountable care

Because each type of managed care organization has certain unique characteristics, network strategies must be chosen to fit these characteristics. An organization that offers more than one type of health plan may choose to coordinate provider networks through a network-within-a-network approach. This is done by including the providers from one product's panel in the network of another panel. Provider network strategies are also found to vary with the geographic scope and market focus of the plan. A growing number of managed care organizations are attempting to build national provider

Managed care in the United States will constantly be changing or evolving. This is due to advances in technology, improvements made by the providers and deliverers of the services, new federal and state laws, and a shift towards a performance based system. Managed care will be delivered to the consumer in an affordable, innovative, and reliable manner with an emphasis on quality and accessibility.

6). We are able to see how these significant events impact us even now. As our health care system continued to evolve, the 1990s saw health care delivery and financing primarily controlled by indemnity insurers, nonprofit hospitals and private physicians (Gabel, 1997, p. 134). Health insurance premiums grew by 20% and enrollment grew from 36.5 million to 58.2 million (Gabel, 1997, p. 134). With the growth of managed care plans, hospitals began to merge and the development of large physicians group practices evolved (Kongstvedt, 2016, p. 14). These roots of managed care grew to give us the health care system we are familiar with now.

Integrated Managed Care Organization- The organization is properly aligned for the primary driver being cost cutting services. Since all entities within the organization are responsible and affected by any expenses endured on any entity being unfavorable or favorable, the foundation serves as a primary motivator to reduce costs at all levels. This alignment eliminates any financial gains from driving high utilization of services or higher intensity services within the organization. Ultimately, this system allows the physician medical group to drive care, being responsible for the clinical care decisions as opposed to health plan making those decisions as designed in other organizations. This is the preferable model for Medicaid systems as

The health care system in the United States has been growing and changing for years and will continue to do so for years to come. The one constant in the Unite States health care system is change and evolution through evaluations of those changes. If there had not been unrest with the level and provisions of care in the early 1970s Managed Care may have never been introduced. President Nixon signed legislation in 1973 termed, Health Maintenance Organization (HMO) Act of 1973. This pivotal event in the health care system allowed for a change from the fee for service model to a comprehensive range of medical or health

The case of Ledina Lushko, a patient enrolled in a Blue Cross and Blue Shield of Illinois individual plan, highlights many of the issues that have plagued the United States healthcare system for some time. As an insurance plan provider, BCBS of Illinois takes pride in the health outcomes of our members and has a responsibility to contribute positively to their care. The fractured, ineffective care Mrs. Lushko received is disappointing, however, this case provides strong support for a shift in focus towards managed care and specifically, the Accountable Care Organization structure. The following details several aspects of Mrs. Lushko’s experience and how her care could have been improved by enrollment in BCBS of

Managed Care Organizations (MCOs) performs three functions: (1) set up the contracts and organization of the health care providers who furnish medical care to the enrollees, (2) establish the list of covered benefits tied to managed care rules, and (3) oversee the healthcare they provide. Managed care greatly influenced the practice of medicine and that the enactment of the Affordable Care Act greatly

It has been said that one cannot know where he or she is going until he or she knows where they has come from. This saying is especially true when discussing the current model of the United States healthcare system. The present day model of the United States healthcare system is the culmination of two hundred years of constant evolution due to ever changing societal norms. America has been in the forefront of major transformations throughout history and there have been integral factors that have been the catalyst for these changes. “Changes driven by

The issue that the hospital faces when a patient necessitates emergent care and is a participant of a managed care organization is the potential of not receiving payment or not being in compliance with EMTALA (Fedor & Perez, 2001). Initially, many hospitals faced many unpaid claims by managed care entities because of their inability to contact the provider for authorization for care (Fedor & Perez, 2001). CMS advised hospitals to negotiate with managed care organizations with future contracts to include a provision for authorization after the patient has received stabilizing treatment with the purpose of remaining compliant with EMTALA (Fedor & Perez, 2001). By modifying contractual agreements between managed care organizations, the hospital can provide emergent care appropriately and ensure that claims are paid by managed

There is an ongoing debate regarding the potency of the new health care reform—Patient Protection and Affordable Care Act—from the outset of its proposal. Many attempts had been presented in the past years but the root of the issue remains prevalent today, that there is a lack of quality in its delivery and the cost of care is continuously increasing beyond national economic edges. In this manuscript, we will discuss several factors that can positively sway the long-term significance, impact, and structure of the United States health care system. Many are wondering whether the Universal Coverage, to which will give more control and

In care policies managed care indicators, online health insurance companies, and optimistic work with the welded doctors and psychosocial centers in the system process to provide medical care ranges for medical members. These pediatricians as well as the centers of medical agents make the attention system of unconscious subconscious policy. In highly managed treatment policies, you can choose to allow only the replacement of medical providers or military medical centers that are members of the corporate Internet policy

The United States’ approach to health care policy is an anomaly among industrialized nations. Disagreement about what the federal government’s role in health care ought to be, combined with the structure of lawmaking institutions, have yielded generations of improvised policies and programs that intend to mollify individual issues created by the health care system rather than comprehensively addressing its flaws.

Managed care was established in order to manage health care cost, utilization, and quality (Kongstvedt, 2015). In managed care, health insurance is provided through HMO, PPO, and other types of managed care. It has the potential to reduced health care spending and improved the quality of care. However, despite of its success in improving the quality of care through preventive health care services, chronic disease management program, and so forth, many physicians are reluctant to be part of the managed care environment. Some of the reasons are the impact of managed care to physician’s income and autonomy. Under managed care, insurers have decreased the fees paid to physicians. There are different ways how managed care organizations control costs. One of this is through selective contracting with health care providers and hospitals to lower costs. In selective contracting, health care providers agreed to accept lower prices in exchanged for guaranteed volume of patients under managed care plan (Culyer, 2014). This paper will discuss more issues and trends in Managed Care Organizations such as the rise of Medicaid Managed Care spending, the new Medicaid Managed care Rule, and the collaboration of Managed Care Organizations and Accountable Care Organizations to reduce health care spending and improve efficiency of care.