Introduction The concept of Health Insurance and managed health care the inventions of the twentieth century that were started as prepaid health care. The early insurance concept was merely a way for people to pay medical bills not a way of protecting individual financial assets as the case is today. Overall the health care industry has endured significant changes since its inception. The early years of Managed care (1910 to mid-1940) The hallmark of this era was the emergence of the prepaid practices and the emergence of the Blue Cross and Blue Shield (the Blue Cross and Blue shield were commonly referred to as the blues). It was noted that most hospital physicians continued to retain the Blues until 1970‘s (Kongstvedt, 2009). The pre-world …show more content…
These early HMOs included the Kaiser Foundation Health Plan, the Health Association in Washington, D.C. Unfortunately, this era also witnessed tumor in the medical community as the American Medical Association (AMA) greatly opposed the prepaid plans of the early 1900s while favoring the indemnity- type insurance that reimbursed policyholders. Therefore with the pioneers of prepaid services encountering daring degrees of oppositions, a strategy to discourage such opposition led to the development of the early Independent practice associations (IPA) model HMO (Fox & Kongstvedt, 2015; Kongstvedt, 2009). Early Years of Managed Care: 1940’s to mid-1960s This era witnessed the expansion of the health benefits. Prior to world war II, only 10% employed individuals had health benefits but, by 1955 the number had increased to 70 %. For example, the health insurance plan of York was created solely for the employees of New York …show more content…
The early parts of this era also, witness the credentialing requirements of the various HMOs across the nation. For example state licensures were mandatory while federal qualifications were regarded as a voluntary act by the HMOs, however, it was in the best interest of the HMO’s to obtaining the approval of the federal government (Fox & Kongstvedt, 2015; Kongstvedt,
The strategic plan for 2015 led to a membership growth of 650,000 members. The main internal driver for the astounding growth, being managed care offered at 20% to 25% less than the surrounding competitors (Brooking Institution, 2015). The more membership growth the more profitable Kaiser becomes based managed care system. Kaiser Permanente’s growth can be related to high scores amongst CMS and it’s highly recommended operation structure amongst the healthcare industry. According to the CMS “2016 Star Ratings Fact Sheet,” Kaiser Permanente represents five of 12 medicare health plans (with Parts C and D) that earned 5 stars — and of the 1.6 million beneficiaries enrolled in those 5-star plans nationwide, 81 percent are Kaiser Permanente Medicare members (Kaiser press release). The Kaiser Permanente Medicare plans since 2009 have always been operating at a high performance
The health care organization with which I am familiar and involved is Kaiser Permanente where I work as an Emergency Room Registered Nurse and later promoted to management. Kaiser Permanente was founded in 1945, is the nation’s largest not-for-profit health plan, serving 9.1 million members, with headquarters in Oakland, California. At Kaiser Permanente, physicians are responsible for medical decisions, continuously developing and refining medical practices to ensure that care is delivered in the most effective manner possible. Kaiser Permanente combines a nonprofit insurance plan with its own hospitals and clinics, is the kind of holistic health system that President Obama’s health care law encourages. It still operates in a half-dozen states from Maryland to Hawaii and is looking to expand...
Niles, Nancy J. Basics of the U.S. Health Care System. Sudbury, MA: Jones and Bartlett, 2011. Print.
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.
Through this organization hospitals and small group practices can be provided with better reimbursements, efficient claim management and better delivery of care by negotiating with the payors and obtaining better health plan contracts. PHOs serve a messenger role between the providers and payors by submitting the fee schedules to the network physicians and enabling efforts to have contracting terms between the providers and payors. Traditionally, the contracts were between the hospitals and payors or small group practices and payors with PHOs as a third party or messenger, but with the emerging trend of clinical integration between the physicians and hospitals PHO enables both the parties involved in the contact agreement which provides better bargaining leverage in negotiation as the collaboration will lead to controlling hospital costs and improving the quality. With the current Medicare and Medicaid payment models involving bundled payments, global payments and episode based payments along with clinical integration between the physicians and hospitals, this Physician – hospital organization arrangement reduces the adversarial or confrontational risk involved by making contracts less complex and reducing the costs by greater cohesion and cooperation between the both parties compared to traditional PHO independent contractual agreements with the insurance companies and payors. Most important concern with the PHO service model is the potential of antitrust liability in the establishing fee schedule and contracting as price fixing arrangements in between the competitors is considered offensive and with the clinical integration between the physicians and hospitals can resolve such issue. Under these arrangements, ownership and governance of the PHO is given emphasis enabling that both the
The first health insurance plans began during the Civil War in the mid 1800’s, with the earliest plans only covering against accidents related to travel via rail or steamboat. Eventually, plans became more elaborate, covering all illnesses and injuries. In 1929, the first modern group health insurance plan was formed. In Dallas, Texas a group of teachers contracted with Baylor Hospital for room, board, and medical services in exchange for a monthly fee. And in 1932, Blue Cross and Blue Shield offered group health insurance plans for the first time (Neurosurgical Medical Group, 2007).
Arguably, all three situations met by the end of the 20th century. The rise of managed care, the increase of health care costs, and the growing number of uninsured patients place economic and political pressures on individuals (and governments) to find a cost-containment resolution. Additionally, since the late 1970s, the medical profession has faced the dominating principle of patient independence as a challenge – first to medical paternalism and then extending even to the principle of beneficence. More so, the usage of the Internet and other global media has expanded the ability of patients to access an...
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. An HMO is a integrated delivery system that combines both the delivery and financial aspects of health care for consumers. Under the HMO, each patient is appointed to a primary care physician (PCP), who is essentially accountable for the long-term care of the members that she/he has been assigned and any specialists that a patient needs to see should be referred by their PCP. Some examples of HMOs are Kaiser Permanente and Humana. HMOs are licensed at the state level, under a license that is known as a certificate of authority. A pro of an HMO is that treatment for a patient can begin prior to their insurance being authorized; A member may benefit from this because there would be little to no treatment delays. A con of an HMO is that in order to save cost, most HMOs provide narrow provider networks; A member may not benefit if in an emergency because their “in-network” emergency room might be far or there are “quick-care” in their
Managed care dominates health care in the United States. It is any health care delivery system that combines the functions of health insurance and the actual delivery of care, where costs and utilization of services are controlled by methods such as gatekeeping, case management, and utilization review. Different types of managed care plans came into development by three major factors. These factors include choice of providers, different ways of arranging the delivery of services, and payment and risk sharing. Types of managed care organizations include Health Maintenance Organizations (HMOs) which consist of five common models that differ according to how the HMO is related to the participating physicians, Preferred Provider Organizations (PPOs), Exclusive Provider Organizations (EPO), and Point of Service Plans (POS). `The information management system in a managed care organization is determined by the structure of the organization' (Peden,1998, p.90). The goal of a managed care system is to provide subscribers and dependants with needed health care services at the lowest possible cost. Certain managed care plans also focus on prevention by trying to keep members healthy.
Barton, P.L. (2010). Understanding the U.S. health services system. (4th ed). Chicago, IL: Health Administration Press.
As progress was made in medicine gradually with new medical technologies which could only be used in the hospitals, doctors started charging more, which was unaffordable for most people, with time, all this started to change as the industrialization of the American economy caused families and people to start relying on services from doctors and the hospitals for treatment. In 1929, a system was created in Dallas, Texas (1) which charged everyone the same. This insurance was to ease the healthcare problem and create a happy scenario for both the doctors and patient, which employers added health to employment packages to boost labor due to shortage after the Second World War. Soon, other private insurance companies were entering the market, thereby creating competition as costs were determined by several factors leaving the sick ones out and insuring healthy people.
An HMO is an organized health care delivery system, which provides health care to its members through networks of doctors and hospitals. Rather than traditional health plans, HMO’s cost less. Two ways HMO’s control costs are: controlling hospital admission and length of stay, and by providing incentives to physicians. These two cost control methods are further examined by an article published by The National Bureau of Economic Research (2002). The article examines the incentives to physician strategy for reducing utilization cost. The Physician Guide to Managed Care (1994) describes HMOs the case management procedures used to control cost through hospital length of stay and admissions.
Traditional insurance companies and HMOs have comparable premium rates. HMOs are too profit oriented and, because of this, their patient care lacks in quality. One way that HMOs cut their costs is to spend less on direct care. As opposed to fee-for-service (FFS) companies, patients relying on their HMO spend 17 percent less time in the hospital regardless of the degree of their illness. This said, patients in Medicare HMOs also spend about 17 percent less time than they would in a traditional setting. It is surprising that, in spite of this fact, Medicare patient risk contracts actually cost Medicare 6 percent
Managed health care actually combines health care delivery with the financing of services provided. This was intended to replace conventional fee-for service plans with much more affordable quality of care to the health consumers as well as the providers who was in agreement with the restrictions. However, managed care is becoming challenged due to the growth of consumer-directed health plans, which defines employer continuations and asking employees to be more responsible within their health care decisions and cost-sharing. The Americans health care system has been changing the way their health care services are organized and delivered. As seen by the movement from traditional fee-for-service systems to managed care networks. Ranging from structured staff model HMOs to the lesser structured preferred provider organizations (PPO). Statistics show that 60 million Americans are enrolled with some type of managed care program within the response to regulatory initiatives which affect health care cost and quality. Managed care organizations are responsible for the health of their enrollees, which can be administered by a physician’s group, health system, or even a hospital. Much of the managed care financing is through a method called capitation, and the enrollees are assigned to a select primary care provider, which serves as a gatekeeper.