As a Health Service Manager in a Managed Care Organization (MCO), one must remain astute in ensuring compliance with the state regulations and expectations for the care of the patients, or members, as they are called, enrolled in the health plan. The population of members the Star Plus Waiver team serves, are the most complex in the health plan. These individuals meet nursing facility level of care. The goal of the health plan is to assist members enrolled in the plan to live in the least restrictive setting as possible. If these members did not have the services in place the nurses on the team provide them access to, they would be living in a nursing facility. Blaise and Hayes (2016) indicated society is saturated with a diverse population of older patients presenting with multiple conditions and comorbidities. With the advent of reimbursement changes, patients are discharged much sooner, despite needing continued skilled care. Because care has shifted to the outpatient and community …show more content…
Because nurses are in the forefront of directly impacting the health of the patient, the more knowledge acquired regarding disease processes and best practice for care, the better. Although returning to school and taking on additional responsibilities is daunting, and it is much easier for a nurse to remain stagnant, healthcare will not remain stagnant and at some point, she or he will have to embrace some form of change for continued success. Healthcare providers are held accountable to those they provide care to. As healthcare providers become more knowledgeable in the field of medicine, they are better equipped to foster positive patient outcomes and reduce mortality. Zimmerman (2013) reported the correlation of improved patient outcomes with higher levels of nursing
According to Statistics Canada Report 2013, “life expectancy in Canada is one of the highest in the world” and it is expected to grow, making the aging population a key driver to our health-systems reform. By 2036, seniors in Canada will comprise of twenty five per cent of the population (CIHI, 2011). Seniors, those aged 65 years and older are the fastest growing population in Canada. Currently there are approximately 4.8 million Canadians aged 65 or greater. It is projected that this number will increase to 9 to 10 million by 2036 (Priest, 2011). As the population get aged the demand for health care and related services are expected to increase. Currently, the hospitals in Ontario are frequent faced with overcrowding emergency departments, full of admitted patients and beds for those patients to be transferred to. It has been reported that 20% of the acute care beds in the hospital setting are occupied by patients that do not require acute hospital care. These patients are termed Alternate Level of Care (ALC). ALC is “When a patient is occupying a bed in a hospital and does not require the intensity of resources/services provided in this care setting (Acute, Complex, Continuing Care, Mental Health or Rehabilitation), the patient must be designated Alternate level of Care at that time by the physician or her/his delegate.” (Ontario Home Care Association, 2009, p.1).
Membership Services (MSD) at Kaiser Permanente used to be a modest department of sixty staff. However, over the past few years the department has doubled in size, creating minor departmental reorganization. In addition the increase of departmental staffing, several challenges became apparent. The changes included primary job function, as well as the introduction of new network system software which slowed down the processes of other departments. These departments included Claims (who pay the bills for service providers outside of the Kaiser Permanente network), and Patient Business Services (who send invoices to members for services received within Kaiser Permanente). Due to the unforeseen challenges created by the system upgrade, it was decided that MSD would process the calls for both of the affected departments. Unfortunately, this created a catastrophic event of MSD receiving numerous phone calls from upset members—who had received bills a year after the service had been provided. The average Monday call volume had risen from 1,800 to 2,600 calls per day. The average handling time for each phone call had risen as well—from an acceptable standard of 5.6 minutes to an unfavorable 7.2 minutes. The department continued to be kept inundated with these types of calls for the two years that these changes have been effect.
To guarantee that its members receive appropriate, high level quality care in a cost-effective manner, each managed care organization (MCO) tailors its networks according to the characteristics of the providers, consumers, and competitors in a specific market. Other considerations for creating the network are the managed care organization's own goals for quality, accessibility, cost savings, and member satisfaction. Strategic planning for networks is a continuing process. In addition to an initial evaluation of its markets and goals, the managed care organization must periodically reevaluate its target markets and objectives. After reviewing the markets, then the organization must modify its network strategies accordingly to remain competitive in the rapidly changing healthcare industry. Coventry Health Care, Inc and its affiliated companies recognize the importance of developing and managing an adequate network of qualified providers to serve the need of customers and enrolled members (Coventry Health Care Intranet, Creasy and Spath, http://cvtynet/ ). "A central goal of managed care is containing the costs of delivering care, but the wide variety of organizations typically lumped together under the umbrella of managed care pursue this goal using combination of numerous strategies that vary from market to market and from organization to organization" (Baker , 2000, p.2).
The IOM report had four key messages needed for advancing the future of nursing. “Nurses should practice to the full extent of their education and training; achieve higher levels of education and training through an improved education system that promotes seamless academic progression; be full partners, with physicians and other health care professionals, …and; effective workforce planning and policy making require better data collection and an improved information infrastructure” (Institute of Medicine, 2011). The report also included eight recommendations needed to facilitate the necessary changes to in the nursing profession so meet to demands of the healthcare reform.
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.
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.
A managed care organization is a collection of clinics, doctors, hospitals, pharmacies and other healthcare providers who come together to offer health care to persons who are sign up for the services. In many cases, managed care organizations operate and are referred to as networks of health care providers. Managed care organizations are comprised of health care experts from different fields who come under an agreement to offer health care services to members. Once a member signs up, all their heath care needs are covered by the managed care organizations. Access to care outside the organization is restricted. Members under managed care organizations are usually assigned a primary care physician (PCP) who is the primary care giver for the member. The PCP is tasked with analyzing a member’s health problem before referring them to other sections of the managed care organization. Managed Care Organizations are usually well coordinated to meet the needs of members who have registered under their banner.
There is a shortage of all health care professions throughout the United States. One shortage in particular that society should be very concerned about is the shortage of Registered Nurses. Registered Nurses make up the single largest healthcare profession in the United States. A registered nurse is a vital healthcare professional that has earned a two or four year degree and has the upper-most responsibility in providing direct patient care and staff management in a hospital or other treatment facilities (Registered Nurse (RN) Degree and Career Overview., 2009). This shortage issue is imperative because RN's affect everyone sometime in their lifetime. Nurses serve groups, families and individuals to foster health and prevent disease.
The field of medicine is a continually evolving field. There are developments in medicine made daily that affect both medical professionals and patients. While the positive progress of medicine offers many obvious advantages, it is important that the knowledge of everyone involved with health care grows with these advancements. With the evident importance of nurses in the healthcare setting, the education of nurses is clearly significant. There are many problems in the nursing field that are associated with the inability to set standards at the entry level (Jacobs et al., 1998). The writer believes that the nursing degree should always be advanced to a bachelor’s degree, and then fostered with continuing education courses. Furthermore, the bachelor’s program should place an importance on forming a good knowledge foundation and then building clinical skills. Ultimately the writer believes a highly clinical and critical thinking bachelor’s program is the best educational preparation for an entry level nurse.
The two major components of Medicare, the Hospital Insurance Program (Part A of Medicare) and the supplementary Medical Insurance program (Part B) may be exhausted by the year 2025, another sad fact of the Medicare situation at hand (“Medicare’s Future”). The burden brought about by the unfair dealings of HMO’s is having an adverse affect on the Medicare system. With the incredibly large burden brought about by the large amount of patients that Medicare is handed, it is becoming increasingly difficult to fund the system in the way that is necessary for it to function effectively. Most elderly people over the age of 65 are eligible for Medicare, but for a quite disturbing reason they are not able to reap the benefits of the taxes they have paid. Medicare is a national health plan covering 40 mi...
Managed care, managed care has become the dominant health care delivery source. Gaining popularity in 1990s, managed care increased from 27% in 1988 to 99% in 2009 and enrollment in Fee for Service plans decli...
Healthcare is viewed in an unrealistic way by most individuals. Many people view a physician as the only means to find a solution to their problem. Nurses are still seen by some as simply “the person who does what the doctor says.” This is frustrating in today’s time when nurses are required to spend years on their education to help care for their patients. In many situations nurses are the only advocate that some patients’ have.
That scientific advances in technology and the advancement of healthcare practices and techniques are inexorably coupled is an undeniable fact. While this tightly knit and dynamic relationship is certainly an exciting prospect, it is also a somewhat intimidating one in that it raises a multitude of questions about how medical professionals can be expected to keep up with a field so dynamic that it changes daily (Taylor, 2008, p. 611). Scientific discoveries may provide the inspiration for creating new, more effective medical practices, but until these advances can be consistently and appropriately applied in a clinical setting, the knowledge gleaned from them is of little use to the progression of medicine as a field. This discrepancy between discovery and actuality demands that nurses, as medical professionals, not only possess the scientific background required to adequately understand and apply the advances that contribute to their field, but also the critical thinking and leadership skills that such a challenging profession requires in order for them to grow and excel in their vocation. It is thus evident that if nurses are to adapt to the changing healthcare climate, they must enter the field equipped with a Bachelor’s Degree of Science in Nursing (BSN) if they are to provide exemplary care and evolve as professionals.
In my medical career, I have been privileged to work alongside some of the most professional, dedicated, knowledgeable and compassionate nurses. I have seen first-hand the difference that they can make in a patient’s life and their family, during those unfortunate times when sickness and injury can be so overwhelming. The appreciation and respect that I have for nurses, as well as their indispensable contribution to the health care system, is what encourage me to pursue nursing as a profession.
Being a registered nurse affords one the option of working in many diverse healthcare settings. In any practice setting the climate of health care change is evident. There are diverse entities involved in the implementation and recommendation of these practice changes. These are led by the Robert Wood Johnson Foundation (RWJF), the Institute of Medicine (IOM), nursing campaign for action initiatives, as well as individual state-based action coalitions. Nurses need to be prepared and cognizant of the transformations occurring in health care settings as well as the plans that put them at the forefront of the future.