...Impact Paper: Development of Managed Care National American University Emily Gregg March 20, 2016 Impact Paper: Development of Managed Care In the early years of healthcare, everything was different. Prepaid medical group practices were created to assure that the clinic had patients regularly, and money coming in. It was the first example of modern capitation, which is a payment per patient per period instead of a fee for service that was previously the standard. This was the early years of managed care. The field has come a long way. Prepaid medical plans became known as insurance, and now there is a variety of them. The aspects that influenced their creation will be discussed, as well as some perspectives between different parties within the field. Some issues have had a large influence on doctor-patient relationship. According to Peter Kongstvedt, some of the issues that impacted the previously stated relationship include cost containment, the development of Managed Care Organizations (MCO) such as Health Maintenance Organizations (HMO), Point of Service plans(POS), and Preferred Provider Organizations (PPO), and the pressures that these MCO’s placed upon the Primary Care Provider (PCP). Prior to MCO’s the provider physician had a main goal which was to manage the patient’s care. In the new MCO plans, the PCP had a new job, a sort of Gate-keeper status between the patient and his or her ability to obtain care that was of higher specialty and cost. The...
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...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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...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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...hard job. They are working with clients, dealing with a great amount of paper work, working with community agencies, and following rules and regulations. When managed care is a part of the equation it is much harder for the case manager due to what is and is not allowed. In this paper I will discuss managed care and how it affects the case manager’s job. What is Managed Care? Managed care consists of a variety of structures, processes and strategies designed to monitor, review, and guide processes of care (Mechanic, 1997). There are several types of managed care, the most popular being HMOs and PPOs. Managed care usually provides a network of providers that the client is allowed to see in order for the client to be covered. Managed care usually allows for the client to only obtain health care and services from those within their network. Here in lies the problem for case managers. Depending on the managed care that the client is under, he or she may not be able to utilize the resources that the case manager has provided for the client. It also may be more difficult for the case manager to find resources that are part of the allowed network within a client’s managed care plan. Managed Care in Case Management Managed care has an exceptional part in how mental illness is treated in our country. It can be very difficult for a case manager to find resources for a client with mental illness because the care they need may not be covered. To reduce costs, insurers tend to cut mental...
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...of this paper is to identify a 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...
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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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...Driven Health Care Morgan Dosher Managed Care Trends L. Ludwig 5/9/2014 Consumer-driven care is a type of health care plan that includes the use of health savings accounts, flexible spending plans or some other sort of savings plan for minor health expenses. Larger expenses for more serious care issues are covered through a catastrophic health insurance plan, which has a large deductible and cannot be used for things such as routine doctor visits. (Goodman, December 2006) The use of a health savings account, flexible spending account or another form of personal savings allows individuals to not worry about whether they are receiving care from an in-network doctor or not. They may seek care from whomever they choose. Further, they alone choose how much to put away in savings for medical issues, and will likely get a choice of different catastrophic plans as well. The main job of any health insurance plan is to prevent the patient from having catastrophic financial losses. While most traditional health plans will also cover more routine matters, this often pushes the cost of those plans higher than they would otherwise be. That is why catastrophic plans were created and the thrust of consumer-driven care. The idea behind patient-centered approaches like consumer-driven care is that if individuals use a health savings plan or flexible spending account, then they will take a more careful assessment of their health care spending, according to a policy brief paper written by...
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...Business Research RES/351 The first article that I chose is named “HMO Access Woes Studied.” The paper is about how HMO patients don't know how to gain access to specialists, don't always know when referrals are appropriate and don't know how to appeal if they have trouble getting referrals. And many physicians (Dependent Variable) don't adequately explain the referral process to patients because they themselves don't understand how it works. Phase one of their study (Independent Variable) involved telephone surveys and focus groups to find out what problems patients and physicians are encountering. With the results being two thirds of the people surveyed and within the focus groups were satisfied with they’re HMO’s while one third said they have encountered problems with referrals to specialists. After analyzing the article, I believe that the hypothesis is HMO’s need to educate not only their members but also the physicians that they contract with, to help members who are not aware of the steps that need to be taken in order to see a specialist for non-emergency appointments. Also, I believe that the process they are using, which is a four step process is a very good way to understand and improve the knowledge of the HMO product. Phase one was the research phase that conducted surveys and focus groups. Phase two will attempt to identify possible solutions that were found in phase one. Phase three involves implementation of the solutions proposed in stage two. Phase...
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...Financing and Structuring Health Care Alicia Rodgers HSA 500 – Health Services Organization Instructor – James P. Driscoll Jr. July 24, 2011 Abstract There are many explanations on how health insurance is financed and structured. In this paper, different types of insured plans are reviewed and broken down to fully understand the design and goal of each policy. Overall, this research is very significant and consistent on the procedures of how these policies were developed. These health insurance plans have their advantages and disadvantages but they all aim as a beneficiary for the purchaser. According to Merriam-Webster, health insurance is defined as a form of policy that provides compensation for medical expenses and loss through illness. Health insurance can be obtained individually from a provider or through an employer or organization. When purchasing health insurance, the policy holder must pay a premium, which is the amount one pays to health plan to keep coverage. Identify and describe the three main types of health insurances in the U.S. There are three main types of health insurances in the United States. They include: Indemnities, Managed Care, and Health Savings Accounts (HAS). Indemnity plans are a fee-for-service plan. It is a flexible insurance that allows the policy holder to choose what physicians, facilities, and services they want. For this plan, the policy holder will pay an annual deductible and the insurance will pay the rest of the bill....
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...Within this paper we will be discussing many aspects of managed health care. That being said, before going ahead and getting into all discussed such as pros and cons, I would like to start this off by discussing what exactly managed health care is. Now let’s ask ourselves this question, what is managed health care? Managed health care is basically a system in which incorporates financial and delivery. This is basically a way for health care businesses to have somewhat of a control on such services. That being said there are many options that fall under such type of organization. In the United States, we have a private and competitive health insurance system which will cause managed care to continue to evolve. Competition and rising costs of health care have even led indemnity plans to incorporate elements of managed care, resulting in fewer "traditional" indemnity plans. There are several key elements common to all managed care arrangements: explicit standards for selecting providers; formal programs for ongoing quality improvement and utilization review; emphasis on keeping enrollees healthy to reduce use of services; financial incentives for enrollees to use providers and procedures associated with the plan. Managed care is a system that integrates the financing and delivery of appropriate health care using a comprehensive set of services. Managed care is a broad term which encompasses many types of organizations and insurance options including: health maintenance organizations...
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...Bernardino County Community Indicators Report, 2014). The largest industries in the county are Trade, Transportation and Utilities, Government, Educational and Health Services, Manufacturing, and Construction. The unique thing about San Bernardino County is that it contains both a mountainous region and a desert region with quite a few regional and national parks. Residents are able to choose from a large amount of outdoor and recreational activities. There are many things to do in the county that ranges from camping and visiting historical sites to checking out different museums in the area. The purpose of this paper is to provide some background information on the county of San Bernardino including its general demographics, socioeconomic status, and the health and wellness of the county. The top 3 health issues in the county are identified and explained. At the end of the paper, solutions and recommendations are given to help with the health issues. County Background General Demographics Population by Age and Gender San Bernardino consists of 2,081,313 people with 95% of the population...
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...MEMORANDUM ON MANAGED CARE TO: Dr. Forney Fleming and the Class of Fall’14 for American Healthcare System FROM: Iyappan Somasundaram DATE: September 10, 2014 RE: Managed Care, Markets and Rationing Briefing Paper MANAGED CARE: An organized way to deliver healthcare services by efficiently utilizing healthcare resources to provide quality patient care. Managed care principles have been used for over 100 years in the U.S. The major goals of managed care include improving quality and accessibility of health care, improving outcomes and overall quality of life for patients and containing costs. The growth of managed care in the U.S. was spurred by the enactment of the Health Maintenance Organization Act of 1973. The organizations that use the above techniques or provide them are called “MCO” or “Managed Care Organizations”. Managed Care organizations are broadly classified into two categories viz. HMO, PPO & POS. During the last quarter of the 20th century, HMOs emerged as an important alternative to traditional medical indemnity insurance plans, and largely supplanted them. This was largely known as the “managed care revolution”. HMOs have had a profound effect on every aspect of the practice of medicine-professional, scientific, social, economic, and legal. HMO (Healthcare Maintenance Organizations): HMOs are comprehensive health care delivery systems that offers a wide range of healthcare services through a network of providers who agree to supply services...
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...Are Doctors accepting Medicaid Patients as Obama has Signed the Affordable Care Act Rider University 2083 Lawrenceville NJ 08648 5/2/2013 Rider University 2083 Lawrenceville NJ 08648 5/2/2013 Arunabh Sinha Arunabh Sinha Abstract On March 23, 2010 President Obama signed into law the Patient Protection and Affordable Care Act (PPACA), also known as Obama Care. As a direct result of this there are going to be more people on Medicaid and also more “baby-boomers” are going to be turning sixty-five thus qualifying for Medicare. Although fewer doctors are accepting government insured patients! This paper will research the number of doctors accepting governmentally insured patients and also if there is a shortage in the number of providers as the PPACA goes into effect. With data provided from the American Medical Association (AMA), Center for Disease Control (CDC), and other academic journals an evaluation is going to be made of if there is enough doctors to meet the demand of newly insured patients in the US. Issues of access and quality of care will also be addressed in this paper. Are Doctors accepting Government Insured Patients as Obama has Signed the Affordable Care Act On March 23, 2010 President Obama signed into law the Patient Protection and Affordable Care Act (PPACA), also known as Obama Care. As a direct result of this there are going to be more people on Medicaid and also more “baby-boomers” are going to be...
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...copayment requirements for health Copyright © 2014 The McGraw-Hill Companies plan benefits. 1.3 Identify the key steps in the medical billing cycle. 1.4 Discuss the impact of electronic health records on clinical and billing workflow. 1.5 Evaluate the importance of professional certification and of medical liability insurance for career advancement. S te p4 Medical Billing Cycle Prepare and transmit claims 1 accounts payable (AP) accounts receivable (AR) benefits cash flow certification coding coinsurance copayment covered services deductible diagnosis documentation electronic claim (e-claim) electronic health record (EHR) fee-for-service health care claim health information technology (HIT) health plan indemnity plan managed care managed care organization (MCO) medical assistant medical billing cycle medical documentation and billing cycle medical insurance medically necessary noncovered (excluded) services out-of-pocket PM/EHR policyholder practice management program (PMP) preauthorization...
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...THE United States, primary care remains a medical model. This is in contrast to much of the world, where the 1978 Declaration of Alma-At a which recognized that attaining health for all also requires interaction from social and economic sectors - is considered standard. Today, there is much buzz about patient-centered medical homes, a concept that promises to transform the practice of American medicine. There is much to praise about this most recent iteration of the medical home. But the missing ingrethent in all these definitions and models remains public health. A population focus that addresses the social determinants of health is an essential component of primary health care. In the United States, such a comprehensive approach has been labeled community-oriented primary care. This model is built firmly on the Alma-Ata principles and incorporates a public health approach to health services. Community-oriented primary care organizes the delivery of health services, around a population, not simply a collection of individuals. It identifies a population - most frequently a geographically defined community - and uses epidemiology and interventions to improve community and individual health and well-being. In this model, both individual patients and the community are the foci of the delivery of health services. Primary health care stands at the intersection of personal and population health services. It requires integrating medical models of primary care that are centered on the...
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