...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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...Financing and Structuring Health Care Assignment #2 Health Services Organization – HSA 500 1. Identify and describe the three main types of health insurances in the U. S. The three main types of are Voluntary Health Insurance (VHI), Social Health Insurance, and Public Assistance or Welfare medicine. Each type of health insurance provides medical benefits which provide payment for medical services rendered. Voluntary health insurance (VHI) can be divided into three categories: BCBS, private or commercial insurance companies and Health Maintenance Organizations (HMO). VHI began in 1929 when Baylor teachers in Dallas, Texas contracted with Blue Cross to provide hospital coverage for three cents a day. This was the beginning of hospital coverage provided by an insurance company. Other states began to provide this same type of coverage for their employees. Since this time health coverage has been extended to provide benefits for physicians, pharmacies and other medical providers. More than 70 years later over 70 percent of the US population under age 65 has some form of VHI, and more than 90 percent of these have health coverage linked through employment. The United States mandates two social health insurance (SHI) programs: Workers Compensation which covers the cost associated with job-related injuries, and Medicare which provides health insurance for the elderly, disabled and other special groups. Workers Compensation provides two basic benefits: cash replacement for...
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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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...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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...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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...strategic management plan of a healthcare organization. My selection is a false managed care organization called GreenLine that is based on a well-known health insurance company that provides a variety of health care plans . In this paper the following will be discussed: factors affecting managed healthcare organizations, strategic initiatives, financial information, and organizational structure. Socioeconomic Factors Socioeconomic status (SES) is an economic and sociological combined total measure of a person's work experience and of an individual's or family’s economic and social position in relation to others, based on income, education, and occupation. Socioeconomic status is typically broken into three categories: low, middle, and high SES. Income has been shown to have a heavy effect on whether families will purchase health care insurance and it’s been proven that people with lower incomes tend to have more problems physically and mentally. Most diagnosis seen are respiratory viruses, arthritis, coronary disease, and schizophrenia. Lower socioeconomic status is also been said to link to stress. Legislative Factors Most recently there has been the ongoing implementation of Patient Protection and Affordable Care Act in the United States which affects all managed healthcare companies and businesses with more than 50 employees. Patient Protection and Affordable Care Act consists of a combination of measures to control health care costs, and expansion of insurance coverage...
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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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... Inc. is an American health insurance company, which is the direct descendant of Aetna (Fire) Insurance Company, of Hartford, Connecticut. In 1850 Aetna began operation of an Annuity Fund and the company would soon to be known as Aetna Life Insurance Company. In 1899 Aetna became one of the first publicly held insurance companies to enter the health insurance field. Since then Aetna has become committed to providing access to cost-effective health care of the highest possible standard, to protect people against health-related risks and enable them to achieve both good health and financial security. Aetna has provided such products and services for 159 years, and has the ability to be a leader in building a strong and effective system of health care by cooperating with health care professionals and public officials (Aetna, n.d). Aetna, Inc. provides a range of traditional and consumer directed health care insurance products and related services, including medical, pharmaceutical, dental, behavioral health, group life, long-term care, and disability plans, and medical management capabilities. Aetna Health Insurance was developed in 1853 and today serves 14.8 million medical members. Aetna is the first national and full-service health-insurer to offer consumer-directed healthcare products (Aetna, n.d). Today, Aetna is one of the nation’s leading health insurance companies which providers top products covering dental which covers 13.1 million members, pharmacy which covers 9.4 million...
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...In recent years the number of Americans receiving health care services through some sort of managed care organization has increased greatly. It’s important to know the difference between the different plans. An indemnity plan was the first type of health insurance. There is no network of providers, meaning the insured can go to any doctor or hospital and there are no co-pays. As an insured with a $500 deductible, the insured would pay the first $500 of any charges. Then they would go into the coinsurance period where both the insured and the insurance company are paying, i.e. 80/20 for typically $5000 to $10,000, costing them around another $1000 to $2000. After that, the insurance company pays everything up to the limit of the policy. There is always an indemnity plan attached to every POS and PPO plan. The advantage to and indemnity plan is that coverage remains the same for any doctor seen and it is ideal in rural areas where there are limited or no PPO or HMO networks. There are disadvantages of course, like any plan. The cost of and indemnity plan is usually much higher than a PPO plan because cost savings are not negotiated with the providers. A PPO almost always has a deductible, and coinsurance. If you stay within the network, there are also co-pays for certain services where the deductible and coinsurance do not come into play. For example, an office visit might be a $15-$40 co pay without regard to a deductible or coinsurance. For a hospital stay, you would be...
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...Financing and Structuring Health Care Strayer University HSA 500 Health Services Organization Mr. David Tataw July 24, 2011 1. Identify and describe the three main types of health insurances in the U. S. The three main types of health insurance in the United States are the commercial health Insurance, Blue Cross and Blue Shield, and Health Maintenance Organization (HMO). The commercial Health Insurance is typically offered by agents or brokers. These insurance carriers’ objective is to make a profit. The commercial health companies are owned by their policyholders or stockholders. Commercial Health insurance is classified by their renewal provision and the benefits it offers to the insured. The coverage includes medical expenses and disability income, which could be long or short term needs. The category of commercial health Insurance companies offer insurance on other property such as home, auto, business etc. (Williams, & Torrens, 2010). Companies that offer a portfolio of services from insurance coverage to pension plan and other financial services are consider multiline carriers (Williams, & Torrens, 2010). Within the commercial health industries, there are companies that are considered single-line carriers that offer health insurance and related employee benefits only (Williams, & Torrens, 2010). Blue Cross and Blue Shield were closely affiliated with the American Hospital Association; their initial focus was on insuring hospitals...
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...Health Care Classification In The United States Identify and describe the three main types of health insurance in the U.S. Managed care, indemnity, and health savings account are the three main types of health insurance in the United States (Three Types of Health Insurance: Indemnity, Managed Care, Health Savings Accounts). Managed care plans are typically more cost efficient due to lower deductibles and copayments. However, patients can only choose from a limited number of physicians and hospitals (Three Types of Health Insurance: Indemnity, Managed Care, Health Savings Accounts). Indemnity plans are based on a “fee for service” system because patients are allowed the freedom to receive services from any hospital, doctor, and/or medical service (Three Types of Health Insurance: Indemnity, Managed Care, Health Savings Accounts). Indemnity plans have been utilized the longer than any of the other plans. However, one of the cons of the plan is that there is no cap on costs that may be incurred to the patient in any given period (Williams, 2008). Health savings accounts give patients to ability to save for future medical costs and/or pay for medical expenses being incurred in the present. Health savings accounts are tax free and composed of two parts: insurance and savings (Three Types of Health Insurance: Indemnity, Managed Care, Health Savings Accounts). Describe the three methods for categorizing health insurance in the U.S. The three methods for categorizing health...
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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 notes...
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...Assignment #2: Financing and Structuring Health Care. 1. Describe and identify the three main types of health insurance in the U.S. Today in the United States, the three main types of health insurances are as follows: 1) Voluntary Health Insurance (VHI): is a private health insurance currently used for industrial employment. It can be subdivided into three categories, such as Blue Cross and Blue Shield, private or commercial insurance companies, and health maintenance organizations (HMO). Blue Cross was initiated by Baylor teachers in Dallas, Texas who organized to provide hospital care for three cents (Williams& Torrens, 2010). The Farmer’s Union started its Cooperative Health Association in 1929 in Oklahoma. It was the first HMO. 2) Social Health Insurance (SHI): This has two major programs sponsored by the U.S. government. These programs are worker’s compensation and pain- related to job injury, and Medicare. Worker’s compensation is the first type of social insurance enacted in a nation and the vast majority of nations worldwide have some form of industrial accident insurance (Williams& Torrens, 2010). It provides two basics benefits, such as cash replacement of portion of wages lost by disability from work injury, and payment for all or part of medical care. For example, a caregiver had back injury upon lifting a handicap patient at the Nursing Home. Medicare is an insurance program run by the Health Care Financing, a federal agency (Robert H. Lee,...
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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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