MANAGED CARE PLANS
Category: Internal Medicine
Abstract :
Managed care plans Definition Managed care plans are health-care
delivery systems that integrate the financing and delivery of health care.
Managed care organizations generally negotiate agreements with providers to
offer packaged health care benefits to covered individuals. Purpose
The purpose for managed care plans is to reduce the cost of health care
services by st
Managed care plans
Definition
Managed care plans are health-care
delivery systems that integrate the financing and delivery of health care.
Managed care organizations generally negotiate agreements with providers to
offer packaged health care benefits to covered individuals.
Purpose
The purpose for managed care plans is to reduce the cost of health care
services by stimulating competition and streamlining administration.
Description
A majority of insured Americans belongs to a managed
care plan, a health care delivery system that applies corporate business
practices to medical care in order to reduce costs and streamline care. The
managed care era began in the late 1980s in response to skyrocketing health care
costs, which stemmed from a number of sources. Under the fee-for-service, or
indemnity, model that preceded managed care, doctors and hospitals were
financially rewarded for using a multitude of expensive tests and procedures to
treat patients.
Other contributors to the high cost of health care were
the public health advances after World War II that lengthened the average
lifespan of Americans. This put increased pressure on the health care system. In
response, providers have adopted state-of-the-art diagnostic and treatment
technologies as they have become available.
Managed care companies
attempted to reduce costs by negotiating lower fees with clinicians and
hospitals in exchange for a steady flow of patients, developing standards of
treatment for specific diseases, requiring clinicians to get plan approval
before hospitalizing a patient (except in the case of an emergency), and
encouraging clinicians to prescribe less expensive medicines. Many plans offer
financial incentives to clinicians who minimize referrals and diagnostic tests,
and some even apply financial penalties, or disincentives, on those considered
to have ordered unnecessary care. The primary watchdog and accreditation agency
for managed care organizations is the National Committee for Quality Assurance
(NCQA), a non-profit organization that also collects and disseminates health
plan performance data.
Three basic types of managed care plans exist:
health maintenance organizations (HMOs), preferred provider organizations
(PPOs), and point-of-service (POS) plans.
• HMOs, in existence for more
than 50 years, are the best known and oldest form of managed care. Participants
in HMO plans must first see a primary care provider, who may be a physician or
an advanced practice registered nurse (APRN), in order to be referred to a
specialist. Four types of HMOs exist: the Staff Model, Group Model, Network
Model, and the Independent Practice Association (IPA).
The Staff Model
hires clinicians to work onsite. The Group Model contracts with group practice
physicians on an exclusive basis. The Network Model resembles the group model
except participating physicians can treat patients who are not plan members. The
Independent Practice Association (IPA) contracts with physicians in private
practice to see HMO patients at a prepaid rate per visit as a part of their
practice.
• PPOs are more flexible than HMOs. Like HMOs, they negotiate
with networks of physicians and hospitals to get discounted rates for plan
members. But, unlike HMOs, PPOs allow plan members to seek care from specialists
without being referred by a primary care practitioner. These plans use financial
incentives to encourage members to seek medical care from providers inside the
network.
• POS plans are a blend of the other types of managed care
plans. They encourage plan members to seek care from providers inside the
network by charging low fees for their services, but they add the option of
choosing an out-of-plan provider at any time and for any reason. POS plans carry
a high premium, a high deductible, or a higher co-payment for choosing an
out-of-plan provider.
Several managed care theories such as those
stressing continuity of care, prevention, and early intervention are applauded
by health care practitioners and patients alike. But managed care has come under
fire by critics who feel patient care may be compromised by managed care
cost-cutting strategies such as early hospital discharge and use of financial
incentives to control referrals, which may make clinicians too cautious about
sending patients to specialists.
In general, the rise of managed care has
shifted decisionmaking power away from plan members, who are limited in their
choices of providers, and away from clinicians, who must concede to managed-care
administrators regarding what is considered a medically necessary procedure.
Many people would like to see managed care restructured to remedy this
inequitable distribution of power. Such actions would maximize consumer choice
and allow health care practitioners the freedom to provide the best care
possible.
According to the American Medical Association, rejection of
care resulting from managed care stipulations should be subjected to an
independent appeals process. The health-care industry today is dominated by
corporate values of managed care and is subject to corporate principles such as
cost cutting, mergers and acquisitions, and layoffs. To thrive in such an
environment, and to provide health care in accordance with professional values,
health care practitioners must educate themselves on the business of health
care, including hospital operations and administrative decision making, in order
to influence institutional and regional health-care policies.
A sampling
of the roles available for registered nurses in a managed care environment
include:
• Primary care provider. The individual responsible for determining
a plan of care, including referrals to specialists.
• Case manager. The
person who tracks patients through the health care system to maintain continuity
of care.
• Triage nurse. In a managed care organization, these
individuals help direct patients through the system by determining the urgency
and level of care necessary and advising incoming patients on self-care when
appropriate.
• Utilization/Resource reviewer. This individual helps
manage costs by assessing the appropriateness of specialized treatments.
Normal results
It is difficult to predict the effect of the managed
care revolution on the health care profession. All health care providers will
benefit from building broad coalitions at the state and federal levels to
publicize their views on patient care issues. These coalitions will also be
useful to monitor developing trends in the industry, including the impact of
proposed mergers and acquisitions of health care institutions on the provision
of care.
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