In the United States, managed care is becoming an increasingly popular method of administering healthcare. It influences the clinical behavior of providers, as it combines the payment and delivery of healthcare into a single system, the purpose of which is to control the cost, quality, and access of healthcare services for a single bracket of health plan enrollees (Scutchfield, Lee, & Patton, 1997).
Yet, managed care often evokes strong or negative reactions from healthcare providers because they are paid a fixed amount for treating their patients, regardless of the actual cost, which may influence their level of efficiency. This can challenge the relationships between doctors and patients (Claxton, Rae, Panchal, Damico, & Lundy, 2012; Sekhri, 2000).
Research managed care’s inception and study some examples. Be sure to investigate the perspectives about managed care from the vantage of both healthcare providers and patients. You can use the following keywords for your research—United States managed care, history of managed care, and managed care timeline.
Based on your research, answer the following questions in a 1– to 2-page Microsoft Word document: INCLUDE REFERENCES
- What are the positive and negative aspects of managed care? Analyze the benefits and the risks for both providers and patients, and how providers should choose among managed care contracts. Conclude with your analysis and recommendations for managed care health plans. Your response should include answers to the following questions:
- Summarize the history of when, how, and why managed care was developed.
- Define and discuss each type of managed care organization (MCO)—health maintenance organization (HMO), preferred provider organization (PPO), and point of sale (POS).
- Explain the positive and negative aspects, respectively, of managed care organization from the provider’s point of view—a physician and a healthcare facility—and from a patient’s point of view.
- Explain the three types of incentives for providers for efficiency in the delivery of healthcare services. Explain who bears the financial risk—the provider, the patient, or the managed care organization.
- Offer your recommendations, to accept or decline, for patients considering managed care health plans, with your rationale for each.
How to solve
Managed care, health and medicine homework help Nursing Assignment Help
Introduction:
Managed care has become a popular approach to healthcare delivery in the United States. It combines the payment and delivery of healthcare services into a single system, aimed at controlling the cost, quality, and access of healthcare services for a particular group of health plan enrollees. However, this approach has been met with mixed reactions from healthcare providers and patients. In this essay, we will summarize the history of managed care and study some examples, define and discuss each type of managed care organization, and analyze the positive and negative aspects of managed care from both the provider’s and patient’s perspectives. Additionally, we will explain the three types of incentives for providers for efficiency in the delivery of healthcare services, who bears the financial risk, and offer recommendations for choosing managed care health plans.
What are the positive and negative aspects of managed care?
Managed care has both benefits and risks for both healthcare providers and patients. From a provider’s perspective, the benefits may include a predictable income stream and reduced administrative burden. The risks include limited freedom of clinical decision-making due to restrictions on referrals to specialists or certain tests, and lower reimbursement rates than fee-for-service plans. Patients may benefit from lower out-of-pocket costs and better access to preventive services. Risks for patients include limited choice of healthcare providers, waiting times for non-urgent services, and limitations on referrals and treatments.
How, when, and why was managed care developed?
Managed care was first developed in the United States in the 1970s as a cost containment strategy for managing healthcare expenses. It was aimed at reducing healthcare costs by managing utilization, coordinating care, and reducing unnecessary services. Managed care organizations (MCOs) combine the roles of insurer, provider, and payer. The goal was to provide quality care at a lower cost by promoting preventive care and reducing the number of unnecessary hospitalizations and expensive tests.
Discuss each type of managed care organization – health maintenance organization (HMO), preferred provider organization (PPO), and point of sale (POS).
Health maintenance organization (HMO) is a type of MCO that offers comprehensive healthcare services to enrollees at a fixed fee. HMOs typically require enrollees to choose a primary care physician who will be responsible for coordinating all healthcare services for the enrollee. Preferred provider organization (PPO) is another type of MCO that allows enrollees to receive healthcare services from a network of contracted healthcare providers at a discounted rate. Point of sale (POS) is a hybrid of HMOs and PPOs. Enrollees can choose to receive services within a network at a discounted rate or seek care outside the network.
What are the positive and negative aspects of managed care organization from the perspective of a physician or healthcare facility and from a patient’s perspective?
From a physician or healthcare facility’s perspective, managed care organizations can help to reduce administrative costs and provide a predictable income stream. However, they can result in restrictions on clinical decision-making, reduced reimbursements, and increased paperwork and administrative burden. From a patient’s perspective, managed care organizations may provide access to needed care, lower out-of-pocket costs, and more efficient care delivery. However, they may limit patient choice and put constraints on referrals to specialists or certain tests.
What are the types of incentives for providers for efficiency in the delivery of healthcare services? Who bears the financial risk – the provider, the patient, or the managed care organization?
Providers are typically incentivized to maintain the health of the patient at the lowest cost while maintaining quality care. The three types of incentives for providers include capitation, fee-for-service, and pay-for-performance. Capitation pays the provider an agreed-upon amount per member per month, regardless of the number of services the patient receives. Fee-for-service incentivizes providers to order more tests, procedures, and treatments by paying more for each service delivered. Pay-for-performance incentivizes providers to achieve certain quality standards by offering financial incentives. The financial risk is usually borne by the managed care organization.
What are your recommendations for patients considering managed care health plans, and what is your rationale?
Patients should carefully evaluate their healthcare needs and financial circumstances before choosing a managed care health plan. Patients who have chronic or complex medical conditions that require specialized care should ensure that the managed care organization they are considering provides access to the specialists they need. Patients should also consider the costs, coverage, and network size to determine whether they can receive high-quality care at an affordable price. The rationale is to ensure that the patient’s healthcare needs are met and that they receive care from providers who are both qualified and competent.
Conclusion:
Managed care has become a popular approach to healthcare delivery in the United States, despite the mixed reactions from both healthcare providers and patients. It is essential for healthcare providers and patients to understand the positive and negative aspects of managed care and to carefully evaluate healthcare needs and financial circumstances before choosing a managed care health plan. By doing so, patients can ensure that they receive high-quality care at an affordable price and that their healthcare needs are met.
