Managed Health Care

Managed Health Care

Managed health care is a system used to control costs, quality of and access to health care services, as well as the delivery of health care services to it’s members. Managed health care started in the 1980’s in response to rising health care costs and new, advancing technology and equipment, which costs more to operate. Members can enroll in one of these three types of health care plans.

Health Maintenance Organization (HMO) is one in which doctors, hospitals, and other health care professionals together form a provider network. They provide services at a discounted rate in exchange for receiving health plan referrals. Then an individual would select a Primary Care Physician (PCP) from a list of approved PCP’s. A Primary Care Physician is also referred to as a “gate keeper” which means a PCP provides, arranges, coordinates, and authorizes all aspects of a patient’s health care. HMO’s are the most restrictive, but provide members with a greater range of benefits for a low out-of–pocket cost, such as a low or no co-payment.

A Preferred Provider Organization (PPO) is similar to a HMO in that they enter into contracts with providers, but there is no gatekeeper and the patient wouldn’t have to use in-network provider care. If one does use in-network care there are better incentives like low co-payments and higher reimbursements. If you choose to go out of the network you may pay as much as fifty percent of your bill.

There is also, Point-Of-Service (POS) this is considered a hybrid of the other two mentioned. With this one you choose which option you want to use each time you visit your physician you can use either HMO or PPO. It too has a contracted provider network and encourages, but doesn’t require ...

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...d to pay them all or they may be over worked because the insurance wants the physician to spend less time with each patient to cut costs, or they are constantly having to battle with the managed care organizations tying up time they could spend helping patients.

Managed health care has changed many patients and providers view of insurance and what is considered necessary care. As a patient one has to be educated in the different types and pick on that is best suited for their needs. As a provider one should evaluate their managed care contract to make sure the amount they are allowed to charge allows them enough time to provide sufficient care also that patients aren’t declined effective health care services. Medical Assistants should be very through in following HIPAA so not to break any guidelines and be able to maintain patient trust and confidence.