...Health Care System Evolution Paper: Managed Care HCS/310 March 12, 2012 Shannon Packard Health Care System Evolution Paper: Managed Care The evolution of the heath care delivery system in the United States has led to the Managed care initiative. “Managed Care emerged at the early 20th century when the United States lacked private and public health insurance” (Rodwin,p. 653, 2010). Managed Care is defined as “any arrangement in which an organization, such as an HMO, another type of Doctor-Hospital network, or an insurance company, act as an intermediate between the person receiving care and the physician (“managed care,” n.d.). Managed care has influenced the current health care system many times over including spurring the creation of HMOs and PPOs. Managed care grew significantly partly in response to physicians and other health care providers charging more and more for services provided in a competition to control the medical market (Rodwin, 2010). These physicians had a serious conflict in interest between trying to sell medical services, in an effort to charge more, and doing what was in the best medical interest for the patient. Managed care has brought about significant change in the way the health care delivery system is handled. Often times, now, a doctor is reimbursed for what is considered, medically necessary, based on a patient’s diagnosis and the normal course of treatment for that diagnosis. They are also reimbursed at a pre-determined rate...
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...Travis Hicks Benefits Administration Fixing the Health Care Plan Health care is an asset that is vital for everyone to have in today’s society. Not having health coverage could bring financial drain or ruin to someone who has become ill. Let alone, if you want insurance later, you may not be able to get coverage due to past and current health situations. Also, you may have to pay a higher premium even if you were approved for coverage due to those past and present conditions. Statistically, you are at a higher risk of dying when you do not possess health coverage. With that being said, Wolfman’s employees understand the importance of the health coverage that they possess through their employer. It is important that I help the employer takes the appropriate steps to ensure that the employees will accept the newly designed insurance program and approve of its initiatives. The biggest area of focus is to provide Wolfman’s with a more affordable health care premium while ensuring that the employees will retain an adequate amount of health care coverage. After observing the current plan that is in place, it looks as if Wolfman’s currently uses a fee-for-service method of coverage. It is common that once a deductible is met, the fee-for-service plan will pay a percentage of the bill, usually %80 percent, and you will pay for the other %20 percent. Under a fee-for-service method, doctors and hospitals will get paid for each service that they perform. There are no limitations...
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...Managed Care Staci Berry MHA614 Policy Formation & Leadership In Health Organizations Instructor: Judy Roberts April 2, 2013 Managed Care In this paper we will discuss managed care. We will find and discuss the definition of managed care. This paper will also explain the different types of managed care plans that are available to Americans. This paper will provide examples of the different types of managed care plans available. It will also explain how each plan works. We will also talk about why rising exposure to health care costs are threatening the well-being of American families. According to Harrington and Estes, managed care is a term that has been overused and really does not have a specific meaning. “Originally, it referred to health care delivered with a capitated financing mechanism. Then it included health care delivered through contracting networks. Currently it refers to most any health are delivery that is different from fee-for-service health care delivery” (Harrington & Estes, 2008 pg.42). When dealing with managed care usually there is a panel of providers that the individual can use. If they go outside of this panel they will be more likely to have to pay a higher copayment or deductible. Some characteristics of a managed care health plan delivery system include: “explicit standards for the selected health car providers, it also puts emphasis on preventive care, as well as provides financial incentives to ensure the use of the...
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...Evolution of Health Care and Timeline Kary Tobine, Raevan Martinez, Rebecca Ornelas, Michelle Veasley, Malissa Krause HCS/531 Health Care Organizations and Delivery System August 17, 2015 Dale Mueller Evolution of Health Care and Timeline Managed Care’s Impact on the Quality of Care Theoretically, managed care was created to cut costs and improve the quality of health care. Reinhardt (1998) states, it was “designed to make the providers’ of health care more accountable for the quality of the health care they deliver.” Thus, selective contracting was initiated. Selective contracting gives health insurance companies the power to decide which hospitals and providers they want in their network (Jiang, Friedman, & Jiang, 2013). This method prompted competition among hospitals and providers to ensure they were always providing and improving quality health care for their patients. Realistically, managed care developed into a very complicated system, leaving many individuals displeased. Studies conducted by Lepolstat, Goldbeck, and Kostelnik (2009) explain, “The quality of health care in the United States has been critically affected by managed health care.” We believe there are three components that measure the quality of care. They are cost, accessibility, and services provided. One of the largest issues with health care today is affordability. Individuals who need health care cannot afford it. Lepolstat et al. (2009) state a third of the population...
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...Effects of Health Care Legislation Presentation The University of Phoenix Misty Oglesby HCS/578: Ethical, Legal, and Regulatory Issues in Health Care Instructor: Qiana Amos November 7, 2011 Effects of Health Care Legislation Presentation How has it or will it affect health care? The purpose of managed care is for administration to have access, control, and quality over health care services within a particular population of enrollees that are covered (University of Washington, 1998). The method of managed care involves a group of skills which persuades the clinical behavior of patients and or providers, done by bringing together the delivery and payment of health care. By using managed care, healthcare administrators are able to develop ways to effectively run healthcare systems by allocating money for departments that are in dire need of funds. Also by implementing measurements that monitor employees work habits, such as how often a nurse should check on patients, how many times a day medications are given, how often bedding is changed, updating charts, and etc. Changing the quality of care, based on customer service, the collaboration of other staff employees, and improved work ethics among staff all has and will continue to affect healthcare. Managed care organizations and doctors use managed care contracts to create the broadest applications possible within the healthcare industry (AMA, 2005). Physician networks, professional corporations, group practices, and...
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...Evolution of Health Care and Timeline Kary Tobine, Raevan Martinez, Rebecca Ornelas, Michelle Veasley, Malissa Krause HCS/531 Health Care Organizations and Delivery System August 17, 2015 Dale Mueller Evolution of Health Care and Timeline Managed Care’s Impact on the Quality of Care Theoretically, managed care was created to cut costs and improve the quality of health care. Reinhardt (1998) states, it was “designed to make the providers’ of health care more accountable for the quality of the health care they deliver.” Thus, selective contracting was initiated. Selective contracting gives health insurance companies the power to decide which hospitals and providers they want in their network (Jiang, Friedman, & Jiang, 2013). This method prompted competition among hospitals and providers to ensure they were always providing and improving quality health care for their patients. Realistically, managed care developed into a very complicated system, leaving many individuals displeased. Studies conducted by Lepolstat, Goldbeck, and Kostelnik (2009) explain, “The quality of health care in the United States has been critically affected by managed health care.” We believe there are three components that measure the quality of care. They are cost, accessibility, and services provided. One of the largest issues with health care today is affordability. Individuals who need health care cannot afford it. Lepolstat et al. (2009) state a third of the population...
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...SUPPORT@WISEAMERICAN.US HLT 205 WEEK 4 COMPLETE LATEST HLT 205 Week 4 Topic 4 Discussion 1 Explain how gatekeeping reduces health care costs in the U.S. Is gatekeeping the most effective strategy for reducing health care costs, or are there more effective strategies that are currently being used? Explain your reasoning with the support of references. HLT 205 Week 4 Topic 4 Discussion 2 Define retrospective and prospective reimbursement methods. In what way did retrospective reimbursement contain perverse financial incentives? Cite reference to support your response. HLT 205 Week 4 Assignment Managed Care Details: The most powerful force shaping the U.S. health care delivery system is managed care. As a health care professional, it is vital that you understand the managed care system, as it impacts all stakeholders. The purpose of this assignment will be for you to demonstrate your knowledge of managed care through a PowerPoint presentation that explains the following: 1. An explanation of what a managed care organization (MCO) is and how MCOs evolved. 2. The identification of the accrediting bodies for MCOs and an explanation of the types of care they oversee. 3. A description of managed care plans, such as HMOs and PPOs. 4. An explanation of the impact of MCOs on cost, access, and quality. 5. An explanation of what an accountable care organization is and its relationship to MCOs. The PowerPoint presentation will be comprised of 10-12 slides with detailed speaker...
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...Contents…………………………………………………………………………………..2 Introduction to Managed Care and the Pros………………………………………….3-4 • Types of managed care • How managed care is governed Cons of Managed Care…………………………………………………………………………..4-5 • Why is there a need for managed care Conclusion……………………………………………………………………………………………..5 References……………………………………………………………………………………………..6 Health insurance plans that contract with health care providers and medical facilities to provide care for members at reduced costs are called managed care plans. There are three different types of managed care plans, and can benefit individuals in different ways depending on the coverage options they are looking for. Like a lot of different things, managed care can have positives and negatives. Managed care is where health insurance companies have contracts with health care providers and facilities to provide care to patients at a reduced price. These providers make up the plan's network. How much of your care the plan will pay for depends on the network's rules and if the provider is in that specific network. There are three different types of managed care; HMO, PPO, and POS. HMO is a health maintenance organization and this is where they usually only pay for care within that network. Some insurance companies like Summa, Anthem Blue Cross Blue Shield, and Medical Mutual offer HMO plans. A PPO is a preferred provider organization which is where they usually pay more if you get care within the network, but they still pay...
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...Quality in Health Care Shanna Marie Fulwood HCA 305 Tessa Guisinger September 17, 2012 Healthcare has become a major issue within recent years. “In spite of its long history and common years the US healthcare system has a complex puzzle to many Americans” (Sultz and Young, 2010, pg XVII). Obama has tried recently to provide access to every individuals they can have some kind of medical care. His new healthcare bill says that everyone has to have medical insurance. This was done because so many Americans are without health care coverage. Now that is mandated we have healthcare coverage what our options? One of the major concerns that we face and always have faced is the quality of care we received. Anyone deserves quality out of the healthcare system. Fortunately there are ways to measure healthcare quality. These tools are mostly used by the professionals. Some questions that will be answered here are how does the quality of healthcare in the United States compared to the quality of care and other industrialized nations; how can an acceptable quality of healthcare be assured for all; will providing data in areas such as patient outcomes, compliance with national standards for preventive and chronic care, and comparative cost to the public be an acceptable measure of healthcare delivery outcomes; the physicians believe that only physicians could and should judge the quality of medical care, they found participation in such hospital peer review activities and most disagreeable...
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...Managed Care Managed care “a health care system with administrative control over primary health care services in a medical group practice. The intention is to eliminate redundant facilities and services and to reduce costs. Health education and preventive medicine are emphasized. Patients may pay a flat fee for basic family care but may be charged additional fees for secondary care services.” http://medical-dictionary.thefreedictionary.com/managed There are many different definitions to what would be considered a managed care. The above is the best and most simple explanation. Providing quality health care services that are economically friendly to the participants are major components to a managed care, all while simplifying and arranging the services that are offered. Managed care programs aim to make sure there are certain standards in place, act as a monitoring service by measuring performance of health care institutions and make sure the cost is reasonable for the members. Some managed care programs also aid members in maintaining a healthy status through annual checkups and routine prevention checks. Managed care plans will often cover all or a large portion of health care services if the members of the plan stay within a certain network of physicians, providers and services. There are times when a manage care plan will allow the plan participants to seek health care services outside the network, however, these services are offered at lower coverage placing more...
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...Manage care is a term that encompasses a variety of restrictions and guidelines for healthcare professionals in order to promote efficient and cost effective outcomes throughout the healthcare environment. The ultimate goal of a managed care system is to produce quality healthcare at a cost that is sufficient to both the system and to the healthcare consumer. In practice Managed Care Organizations take a variety of shapes and thus there is no one fit all model that works ideally for each type of healthcare organization. In terms of the disease management of chronic long-term conditions, MCOs can offer services at cheaper cost than the fee-for-service model. A key function of a manage care system with a disease management inclusion is the integration between all of the providers providing care. This paper will primarily act to define disease management and give a brief overview of its clinical framework....
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...Capitation vs. Fee-for-Service Article Review HS546 HS546 Article Review Capitation vs. Fee-for-Service It seems that even the aspect of how health care cost should be paid is an every evolving problem in the United States. The Article Capitation Is for Specialist, Not for Primary care Physicians, describes transition to a group Capitated pooled system for Specialist. In addition to an every changing health care system and the introduction of Managed Care, there is also a shift towards capitation to fund health care. Most physicians have been paid through a Fee-for-service type setup for much of the 20th century. In an article from Health Care Financing & Organization News & Progress, researchers discuss capitation as one of the three worst forms of payment for physicians. James Robinson from the University of California states that Capitation rewards the denial of appropriate services, and leads to the dumping of chronically ill patients, and also narrows’s the scope of practice (http://hcfo.net/pdf/news1200.pdf). The Idea of Capitation is to control cost and limit physician’s ability to over prescribe or treat a patient. Capitation is negotiated with the insurance company to provide a fixed amount of dollars per month for patient care. This amount is fixed per month regardless of services rendered if the clinic goes over the amount of capitation; they are responsible for eating the cost, not the insurance company. This introduces financial risk to the organization...
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...HSMA 4075-Managed Care in Health Systems Gynecologists as the Primary Care Physician? Sonya M. Artis September 11, 2008 Gynecologists as the Primary Care Physician? In managed health care the primary care physician has a role that is very significant to the delivery of care. A primary care physician serves as the initial contact for a person with an undiagnosed medical concern and they are responsible for the continuum of care for varied existing medical conditions. These conditions are not limited by diagnosis, organ system, or cause. Ordinarily, a primary care physician does not specialize in any medical specialty, such as neurology, oncology, pulmonology, or gastrology. However, the concept of the gynecologist as the primary care physician remains arguable. In comparison to the primary care physician the obstetrics/gynecologist also plays a vital role in the health care treatment plan---for women. As a result, some managed care organizations (MCOs), health maintenance organizations (HMOs) and indemnity health insurers may allow the gynecologist as the primary care physician. According to Kongstvedt, many obstetrics/gynecologists (OB/Gyn) feel as if they indeed deliver primary care. They make this assertion because “they are often the only physician a young woman sees for many years” (66). Healthy women do not always have medical concerns until problems arise with their female reproductive systems. Therefore, care provided by...
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...1. Identify 8 managed care contracting terms: a. Administrative services only (ASO): Usually associated with self-funded groups, this is when an insurance company, HMO, or third-party administrator provides claims-processing services, but the employer pays the claim costs. Administrative services usually include billing, enrollment, and coordination of benefits, payment check processing, subrogation, fraud investigation, and network rental. b. Coordination of benefits (COB): Provision regulating payments when a person is covered by more than one healthcare policy. For example, if an employee is covered under a group plan and also under a spouse’s plan, the companies will coordinate payment of benefits so that each company pays the correct portion of the charges and doesn’t reimburse the claimant for more than the cost of the medical care. c. Cost sharing: A broad term representing the ways in which a covered member shares in the cost of healthcare services with the health plan. Examples of this include deductibles, co-payments, and coinsurance. d. Exclusive provider organization (EPO): A term used to describe a health plan that is similar to an HMO in that it provides benefits only if the insured uses the specified network of providers, but is usually offered as an insured or self-funded product. EPOs usually mandates that coverage be channeled through a primary care physician. Also, EPOs is governed by the state’s Department of Insurance, as are PPOs...
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...a Community Health Centers? Community health centers are public or non-profit clinic sites located in medically underserved, rural, and urban areas throughout the nation. They receive grants under the Community and Migrant Health Centers Program of the US Department of Health and Human Services to provide primary and preventive care to community residents. Community health centers remove common barriers to care by serving communities that otherwise confront financial, geographic, language/cultural and other barriers, making them different from most private, office-based practices. CHCs are: • Located in high-need areas identified by the federal and state government as having elevated poverty, higher than average infant mortality, and where fewer providers agree to practice; • Open to all residents, regardless of insurance status, and provide reduced cost care based on ability to pay; • Tailor services to fit the special needs and priorities of local communities, and provide services based on the advice of local residents, businesses, churches, and other organizations; and • Offer services that help patients access health care, such as transportation, translation, case management, health education, and chronic disease management. Health centers are required by law to provide: • Basic health services related to family medicine, internal medicine, pediatrics, obstetrics, or gynecology; • Diagnostic laboratory and radiology services; •...
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