Peer review

b. Cons Associated with Managed Care……………………………………….…7

V. Challenges and Problems Associated the Pros and Cons of Managed Care…………..7

VI. Challenges/Problems Analysis………………………………………………………...9

VII. Recommended Solutions……………………………….………….…………………10

VIII. Implementation of Solutions……………………………………….…………………11

IX. Justification……………………………………………………………………...……12

XI. References…..………………………………………………………………..………14

Abstract

Managed care is one of the leading forms of health care in the United States. Health care practitioners, institutions, insurers and patients are working to increase access to health care at a lower cost without sacrificing quality care. This paper reviews the pros and cons of managed care as well as challenges and problems. Recommended solutions to the challenges and problems are also discussed.

Introduction

Managed health care is a health care insurance method in which patients agree to visit only certain doctors and medical facilities.  One goal is to lower the overall cost of care as a managing company keeps watch on the financial results. This paper examines and analyzes the pros and cons of managed care.  

Background

According to Medicaid.gov managed care is defined as “a health care delivery system organized to manage cost, utilization, and quality.” The sole purpose of managed care is to provide affordable prepaid health care services to those enrolled who are employees and or beneficiaries who joined a managed care plan. There are three types of managed care plans including: HMOs, PPOs, and POS plans.

As per MedMutual.com a Health Maintenance Organization (HMO) is a health care plan that has its own network of doctors, hospitals and other health care providers that agree to take payments at a certain level for the services they provide. HMOs allows its users to reap the benefits of lower cost and the choice of providers. Regarding HMOs you must first select your primary care physician (PCP) who then becomes responsible for all your health care needs and if at any time you need to see a specialist you must first visit with your PCP who must then refer you to a specialist.

MedMutual.com defines a Preferred Provider Organization (PPO) as a “partnership in which medical professionals and facilities provide services to clients at a reduced rate”. Although the definitions of HMOs and PPOs are very similar there are differences. PPOs offer more flexibility. PPOs allows you to choose from whom you receive care in or out of your network. Although a PPO affords the beneficiary more choices it will also mean higher out of pocket cost.

Point of Service Plan (POS) is defined as a “type of managed care plan that is a hybrid of the HMO and PPO plans” (healthcoverageguide.org). With this type of plan a primary care physician is assigned within the network. Patients may seek care outside of the network, but this will mean they must cover the cost on their own unless the primary care physician provides a referral, then their plan will cover the cost.

In the United States the beginnings of managed care can be traced back to the late 19th century. It all began when a small group of physicians throughout different cities within the United States started offering prepaid medical care to unions and other associations. The members of these groups were only required to pay a small annual fee to the physician which allotted them unlimited access to health care services.

During the great depression organizations like lumber, mining and railroad companies began offering their own medical services. By 1973 the HMO Act was passed, which according to Essentials of Managed Health Care “It authorized startup grants and loans and, more importantly, ensured access to the employer-based insurance market.” (p.7) This act provided a financial stepping block for developing HMOs and required that employers must offer their employees the option of coverage from at most one qualified HMO. In the 1980s the prospective payment system which is defined by cms.gov as “a method of reimbursement in which Medicare payment is made based on a predetermined, fixed amount”, was initiated. Through this system the amount paid was solely based on the classification system of the service rendered.

In the 1990s a capitated agreement, which is a payment of a fixed rate for every patient covered by the plan, was initiated. In 2010 the Affordable Care Act also known as ObamaCare was passed which made affordable health care available to more people, expanded the Medicaid program to cover individuals with an income well below the poverty level in some states and improved the way in which health care was delivered. Today Managed Care has continued to grow and be a fundamental component in the delivery of health care and serves as a facilitator between the provider and the patient.

Review of the Literature

Pros Associated with Managed Care

Managed care is one of the leading forms of health care in the United States. Options available to individuals are preferred provider organization (PPO), health maintenance organizations (HMOs) and point-of-service (POS) plans (Cyrene, 2018) with different co-pays. With managed care less of the health care dollar is spent on prescription drugs. Patients use less expensive, generic drugs for their treatments and see lower costs for their drug co-payments (Jackson). There is also a lower cost associated with health care provided to the members. Health care costs are lower without sacrificing quality.

Another advantage of managed care is the network of readily available health care providers and facilities that have been evaluated and assessed through an accreditation process with denotes that they have met the standards as outlined by the profession (Cyrene, 2018).

Cons Associated with Managed Care

There are also disadvantages to managed care. Patients in some plans can only see a specific health care provider if that provider is within their approved network. Most managed care plans restrict where the patients can go to receive care. If a patient wants to see a provider outside their approved network, they most likely would have to pay out-of-pocket (Jackson). Because most managed care plans place restrictions on where patients can go to receive care, patients who want to see a specific doctor will often have to spend more in out-of-pocket costs to see those physicians. Many patients in a managed care plan complain about the long wait times to get appointments, inconvenient venues for practitioners and that available appointment times are not a good match for their work and family life schedules (Cyrene, 2018).

With managed care providers must take into consideration the patient’s plan before referring to a specialist (Jackson). In managed care what insurance companies are willing to fully or partially cover is very strict. You must speak with an insurance company representative to discuss your issue before you can be approved for treatment. With the strict approval with managed care, approval for pre-existing conditions are often difficult (Vittana, 2018). Patients also do not like their loss of privacy that they often encounter with managed care. Patients dislike the fact that the managed care company receives detailed summaries of treatments, and medical conditions. (Cyrene, 2018).

Challenges and Problems Associated with the Pros and Cons of Managed Care in America

This section discusses the challenges and problems associated with the pros and cons of managed care in America. Since there are no challenges and problems associated with the pros of managed care, the focus of this section is on the challenges and problems associated with the cons of managed care.

Some of the challenges and problems associated with cons in managed care include restricted services, referral issues, strict approvals, loss of privacy and long wait times. In managed care the restriction of services is a big issue. In managed care you can only visit doctors that are within your network and those options are limited. For example, if you aren’t satisfied with the treatment you are getting there may not be another in-network provider that is accessible through your plan and receiving a second opinion outside of your network more than likely will not be covered by your insurance.

The fear of the loss of privacy is the same in managed care as it would be anywhere else. In managed care during the treatment planning and payment process summaries of an individual’s medical file contains sensitive information. Although there are policies and procedures in place to protect patient information, nothing is full proof and there is no way to validate that someone’s information is completely safe.

The long wait times have increased since the passing of the Affordable Care Act due to increased access to healthcare to millions who were uninsured. Because of the Affordable Care Act more people are visiting doctors and seeking care. The downside is that there are not enough physicians that are within those networks to meet the needs of the number of patients that were coming in. The longer wait times have made it difficult to speak to a doctor or receive regular checkups.

Challenges/Problems Analysis

Typically, the challenges/problems facing health care in the United States can be evaluated since all managed care is not the same. All plans do not offer customers the same opportunity and value for their money. The largest difference exists between the not-for-profit plans and the for-profit plans. In the case of the for-profit plans, about 65-70% of spending goes to actual medical care while the remaining percentages go to marketing expenses (Roberts, 2016). On the contrary, the not-for-profit plan makes a spending of over 90% of the premium income specifically on patient care. This aspect depicts how expensive it has been even with managed care. The for-profit plans minimally focus on making care affordable to most people in the country (Roberts, 2016).

Health care economists have stated that managed care has achieved more than the credit received for it, but it also came with many issues. Future forecasts on the managed care predict significant changes due to the current problems. One of the major problems is the rush, usually by the for-profit, for care without the consent of practitioners or patients (Roberts, 2016). As a result, this care has been priced out of the market. The system is failing because it has become increasingly expensive and bureaucratic. It currently denies care to many people in need. Many Americans are dying young because they can no longer afford care without insurance coverage. The system has caused people to receive less care and face greater restrictions.

Individuals are increasingly becoming less satisfied and spend more on health care than the amount spent by patients in similar economies such as Canada and the United Kingdom among other countries (Roberts, 2016).

Recommended solutions

The healthcare industry has witnessed and endured many opportunities and challenges. However, this industry continues to formulate different strategies and recommendations to implement in hopes to overcome the challenges occurring over time. The first recommendation is to increase the capacity and strength of the health care safety net. To achieve improved access, there must be an increase in the number of health care facilities and practitioners to increase the availability of services to those who disenfranchised (underserved, disadvantaged, geographically isolated, and special needs groups) (HRSA, 2016). One such case happened in Chicago. In this instance there had been one level 1 trauma center located on the west side of Chicago. This was a major issue for this city; given the ongoing violence occurring within Chicago daily. It was stated on the news that countless of gunshot victims died while in route to Northwestern trauma center, coming from the south side of Chicago. To hopefully correct this issue, there has been a new level 1 trauma center built within the University of Chicago emergency department. This made available a trauma center on both the south and west sides of Chicago.

The second recommended solution would be to improve the quality and efficacy of the health care safety net. To accomplish this there must be practical assistance and other support for institutions and practitioners so that persons served by HRSA programs receive quality, comprehensive, family-focused health care across all ages and medical homes (HRSA, 2016). For example, patients may differ by ethnicity, religion, language, etc. One example of quality and efficacy being improved would be to offer a language interpreter. Within various healthcare facilities there are language interpreter machines available for staff and patient use. Having an interpreter breaks the communication barrier allowing staff and patients to have better communication. Another example that improves the quality and efficacy of the safety net is the implementation of the “My Chart” healthcare application. This application allows for patients to access their medical chart as well as communicate with providers.

A third recommended solution would be to increase enrollment in the utilization of health insurance through Medicaid, CHIP and the Health Insurance Marketplace (HRSA, 2016). Usually individuals do not have health coverage due to a lack of financial resources. To improve the health of individuals who did not have health care the Affordable Care Act was passed. The Affordable Care Act created new avenues for customers to apply for and enroll in Medicaid, CHIP and Basic Health Programs.

Implementation of Solutions

To implement the recommended solutions will involve increasing the capacity and strength of the managed care safety net. One way to accomplish this task is to match treatment to the patient needs and predictions rather than using primarily broad generalizations. The capacity and strength of the safety net will also increase if quality and efficiency are improved. The use of technology can improve statistical predictions and ensure greater patient compliance. Simple measures such as using repeated reminder text messages result in fewer missed appointment. The focus should be on “intensity of services” rather than on numbers or profits. Both patients and health care providers should be accountable for improvements. Cost should not be a determining factor in whether critical care is available or administered (Brennan, 2009).

The cost of health care and insurance continues to rise even though the increase has slowed since the implementation of the Affordable Care Act. One way to keep the cost of insurance down is to enroll more individuals, especially young, healthy people. Advertising, incentives, and promotions to employers can help with that increase.

Justification

The recommended solutions as stated above are justified because they work together to provide a multifaceted health care paradigm that will result in the delivery of quality patient care. The increase of capacity and strength of the healthcare safety net will increase the number of access points needed for patients as well as facilitate the recruitment of providers in underserved communities to improve their access to care. These recommendations will strengthen healthcare and other networks through policy development and funding to make sure services are delivered effectively.

Improving the quality and efficacy of the healthcare safety net is needed to provide technical support and more to providers and to ensure that those serviced by these programs continue to receive quality care throughout their entire life. The goal is also to work with safety net providers and networks in hopes that they will participate in a value-based payment system.

Lastly, the increase in the enrollment in the utilization of health insurance is important because it will aid those who do not have coverage and help them understand the benefits, primary care and preventive services that will be available to them once they’re covered.

Summary and Conclusion

There have been many changes over time to Managed Care in America. It has been traced to the early nineteenth century where small groups of physicians provided some prepaid medical care to different unions. It has grown from just covering a few unions by different physicians to helping to cover millions of people throughout the United States. With the growth of the economy there has been a tremendous growth in managed care organizations (MCOs). Following all the growth that the MCO has had over the last century, there has been many obstacles and benefits that they have faced.

With managed care there have been different issues such as restricted care, strict approval for services, referral problems, extremely rigid rules, the necessity for self-advocacy, dollar and cents taking priority over individual needs, loss of privacy, and long wait times. There has been a multitude of issues that have been assessed and refined. Focusing on just the disadvantages would not be a best practice. There are also many advantages to in managed care. Lower cost for insurance coverage, accredited care, lower cost prescriptions, rapidly-moving information within the network, keeping families together, and guarantee of care within the network are just a few of the pros that are seen in managed care.

References