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Discuss the advantages and disadvantages
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The rapid growth of managed care is the response to limited financial resources and the demand for healthcare services to be affordable. Economic viability is a crucial aspect of health care. Managed care plans were developed to provided health care services, but also to be a method to collect payment for services. There are different types of managed care plans. For example, health maintenance organization (HMO), preferred provider organization (PPO), and point-of-service (POS) plans. For brevity of this paper the HMO managed care system will be discussed along with the relevance of the role of the advance practitioner practicing in HMO setting.
The 1970's need for primary care settings to curtail and control cost for employee benefits caused the development of the group practice model or also known as a HMO (Anderson & O’Grady, 2009, p. 380). HMO is a type of a managed care system created in an effort to provide health care to a large group of people. Its purpose is to provide health care services at a lower cost and often at a fixed cost. The HMO plan is based on obtaining authorized health care services by utilizing "in-network" providers. This meant the plan under that HMO will only cover the physicians and services which are authorized. If, for some reason, a specialist or extended service, such as admission to the hospital or rehabilitation service may not be authorized the "out-of-network "service must be approved by the HMO provider. The advantage to "in-net-work" and limiting health care service under a plan is control cost. The cost under these plans are none to a small percentage of "out-of-pocket" expense at the time of service. The disadvantage of this type of plan is only "in-network" physicians or serv...
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...09, p. 384). NPs are able to see patients with the minor health problems. Therefore, freeing up physicians to attend to the more serious ill patients.
References
Anderson, A. R., & O’Grady, E. T. (2009). The Primary Care Nurse Practitioner. In A. B. Hamric, J. A. Spross, & C. M. Hanson (Eds.), Advanced Practice Nursing an Integrative Approach (4th ed., pp. 380-402). St. Louis MO: Saunders.
Aspen . (2008, September 1). Managed Care. Managed Care Outlook, 21, 1-6. Retrieved from http://web.ebscohost.com.ezproxy.graceland.edu
Hit Where it hurts why HMO profits are shrinking fast. (1997, October 27, 1997). Business Week, 42 - 43. Retrieved from http://web.ebscohost.com.ezproxy.gracedland.edu
Stevens, A. B., & Sanghi, S. (2010). Emerging frontiers in healthcare research and delivery. Clinical Medicine & Research, 3, 176 -178. doi: 10.3121/cmr.2010.974
It is enthralling to note that in spite of the advances in healthcare systems, such as our hospital’s ability to provide patients with lower cost, managed One being the Health Maintenance Organizations (HMO), which was first proposed in the 1960s by Dr. Paul Elwood in the "Health Maintenance Strategy”. The HMO concept was created to decrease increasing health care costs and was set in law as the Health Maintenance Organization Act of 1973, after promotion from the Nixon Administration. HMO would, in exchange for a fee, allow members access to employed physicians and facilities. In return, the HMO received market access and could earn federal development funds.
A multispecialty group practice is one that consists of individual physicians who offer various medical and specialty services in that practice by contracting to a managed care plan. Managed Care Organizations are formed by insurance companies that either own a provider network or create one by arranging with independent providers (Gapenski, 2009). The payment structure used to reimburse providers regardless of services provided falls into the category of either fee-for-service or capitation based. Fee-for-service is the reimbursement according to services provided, either through reimbursing based on the cost of services provided or reimbursing based on rate schedule of services provided. On the other hand, in the Capitation system, providers are paid a fixed amount depending on the number o...
When one examines managed health care and the hospitals that provide the care, a degree of variation is found in the treatment and care of their patients. This variation can be between hospitals or even between physicians within a health care network. For managed care companies the variation may be beneficial. This may provide them with opportunities to save money when it comes to paying for their policy holder’s care, however this large variation may also be detrimental to the insurance company. This would fall into the category of management of utilization, if hospitals and managed care organizations can control treatment utilization, they can control premium costs for both themselves and their customers (Rodwin 1996). If health care organizations can implement prevention as a way to warrant good health with their consumers, insurance companies can also illuminate unnecessary health care. These are just a few examples of how the health care industry can help benefit their patients, but that does not mean every issue involving physician over utilization or quality of care is erased because there is a management mechanism set in place.
Health Maintenance Organizations, or HMO’s, are a very important part of the American health care system. Also referred to as managed care programs, HMO's are combinations of doctors and insurance companies that are formed into one organization. This organization provides treatment to its members at fixed costs and decides on what treatment, if any, will be given based on the patient's or doctor's current health plan. Sometimes, no treatment is given at all. HMO's main concerns are to control costs and supposedly provide the best possible treatment to their patients. But it seems to the naked eye that instead their main goal is to get more people enrolled so that they can maintain or raise current premiums paid by consumers using their service. For HMO's, profit comes first- not patients' lives.
" Journal Of The American Academy Of Nurse Practitioners 24.12 (2012): 726-734. Academic Search Premier -. Web. The Web.
Formed in 1998, the Managed Care Executive Group (MCEG) is a national organization of U.S. senior health executives who provide an open exchange of shared resources by discussing issues which are currently faced by health care organizations. In the fall of 2011, 61 organizations, which represented 90 responders, ranked the top ten strategic issues for 2012. Although the issues were ranked according to their priority, this report discusses the top three issues which I believe to be the most significant due to the need for competitive and inter-related products, quality care and cost containment.
The key to a successful healthcare reform is interdisciplinary collaboration between Family Nurse Practitioners (FNPs) and physicians. The purpose of this paper is to review the established role of the FNP, appreciate the anticipated paradigm shift in healthcare between FNPs and primary care physicians, and recognize the potential associated benefits and complications that may ensue. Description of the Topic Definition The American Nurses Association (2008) has defined the FNP, under the broader title of Advanced Practice Registered Nurse (APRN), as one “who is educationally prepared to assume responsibility and accountability for health promotion and/or maintenance as well as the assessment, diagnosis, and management of patient problems, which includes the use and prescription of pharmacologic and non-pharmacologic interventions” (p. 7).... ... middle of paper ... ...
Typically NP’s provide health services in rural areas where they are the only source of medical services and this had n...
Willis, E, Reynolds, L & Keleher, H 2012, Understanding the australian health care system, Mosby Elesvier, Chatswood, NSW.
As an advanced practice nurse (APN), one must interact with other medical professionals cooperatively and collaboratively to ensure the best outcomes for his or her patient population. Interprofessional collaboration happens when providers, patients, families, and communities work together to produce optimal patient outcomes (Interprofessional Education Collaborative Expert Panel, 2011). This type of teamwork and cooperation ensures that all of the providers caring for a patient act in a cohesive manner in which everyone including the patient plays a role in the management of the individual’s health. The purpose of this discussion is to evaluate interprofessional practice and provide the view of a
McDonough, John E., and Eli Y. Adashi. "Realizing the Promise of the Affordable Care Act--January 1, 2014." JAMA: The Journal Of The American Medical Association 311.6 (2014): 569-70. Print.
Managed health care is the leading form of health care in the United States. The most common forms of managed care providers are Health Maintenance Organizations (HMOs) and Preferred Provider Organizations (PPO’s). The main advantage of managed health care is the lower costs associated with them. The goal of managed care is to keep health care costs down without sacrificing quality. Consumer-driven healthcare plans are beginning to emerge and grow across the country (Weaver, 2010). Consumer-directed healthcare plans are popular for employers because more of the decision making and risks fall on the employees. Therefore, reducing the amount of money the employer spends on healthcare.
What is the central component of advanced practice nurses (APNs) direct clinical practice and patient/families?
The APRN listens and engages with the patient as care and compassion take place. As the nurse discerns what the patient’s needs are and considers obstacles to achieving optimal care the application of theory is necessary as the process is not always quantifiable. The APRN who does not learn nursing theory may focus primarily on EBP and miss this engagement opportunity with the patient. One may prescribe medication; however, if the patient does not take the medication, then the nurse assumes the patient is noncompliant. The application of Watson’s themes where appropriate helps the APRN discern how to help the patient become compliant. It is necessary to care for the patient outside of the idea of only providing care to understand the obstacle in that patients circumstances and reach improved patient outcomes to any disease
There are several benefits of being a part of an HMO, especially for the providers. For instance, under some managed care organizations (typically IPAs or PPOs), providers are provided a straight salary (Hicks, 2014). Under salary compensation, a physician’s income is not affected by treatment choices made. Also, under another alternative, capitation, a physician receives a certain sum per patient, irrespective of what services are provided to the patient (2014). The disadvantage with that is that an extreme form of capitation would pay a primary care physician receives a certain sum per patient and makes him or her financially responsible for all care (2014). Hicks posits that this provides a very strong incentive to limit the care provided and puts the physician at great risk if a patient should need treatment for a catastrophic illness