Managed Care Organization
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.
Managed care organizations are created on the basis tha...
Balance sheet lists assets, liabilities and owner’s equity. The assets listed on the balance sheet are acquired either by debt (liabilities) or equity. “Companies that use more debt than equity to finance assets have a high leverage ratio and an aggressive capital structure. A company that pays for assets with more equity than debt has a low leverage ratio and a conservative capital structure. That said, a high leverage ratio and/or an aggressive capital structure can also lead
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).
Integrated Managed Care Organization- The organization is properly aligned for the primary driver being cost cutting services. Since all entities within the organization are responsible and affected by any expenses endured on any entity being unfavorable or favorable, the foundation serves as a primary motivator to reduce costs at all levels. This alignment eliminates any financial gains from driving high utilization of services or higher intensity services within the organization. Ultimately, this system allows the physician medical group to drive patient care, being responsible for the clinical care decisions as opposed to health plan making those decisions as designed in other organizations. This is the preferable model for Medicaid
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...
What is managed care? According to the Oxford English Dictionary, managed care is “a system of health care in which patients agree to visit only certain doctors and hospitals, and in which the cost of treatment is monitored by a managing company.” Managed care is a variety of techniques designed to reduce the cost of providing health benefits and advance the quality of care. In the United States alone, there are various managed care programs, that are ranged from more restrictive to less restrictive. As stated in the National Institutes of Health, the future of managed care is uncertain. 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
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...
Health Maintenance Organization (HMO) is a group of individual health plans that are intended to provide services for costumers’ that purchase insurance policies and for those that cannot afford health insurance. Many of these organization are led by physicians, and other professionals that network together to make health care affordable for patients. In the HMO category there are five separate managed care plan models. First, the Group Model (HMO), is a group that has a number of physicians that mainly agree to provide care to a defined group of patients in return for a fix rate capita payment for discounted fees from insurance companies (Henderson, 2012 p.212).
The current focus on new healthcare models is a reaction to long-standing concerns around quality, cost, and efficiency. Accountable Care Organizations model focus on integrated healthcare to promote accountability and improve outcomes for the health of a defined population. The goal of integrated healthcare is to ensure that patients, especially the chronically ill, get the right care at the right time, while avoiding unnecessary duplication of services and preventing medical errors (CMS, 2014). The following paper will analyze an ACO’s ability to change healthcare in the United States.
For patients, when ACOs are fully functional they represent an increase in patient experience in several ways. First ACOs allow open communication between physicians from different specialties coordinating together to determine solutions. Second, ACOs also establish a single point of contact for all questions concerning care. Finally, these organizations represent a centralized network of physicians for the patient, creating a team to deliver comprehensive care. In fact, there is mounting evidence that suggests the potential benefits of care coordination in ACOs for both patient experience and quality, including reduced hospital admissions, improved quality of chronic disease management, improved patient satisfaction, and better access to specialty care (Stille, 2005). For providers, ACOs provide an opportunity for better collaboration on the various modalities they use on their patients, as well as improved workflow and communication. There are several stakeholders in which the large scale implementation of ACOs would affect. Federal and state government health insurance programs like Medicaid and Medicare, one type of stakeholders. With the implementation of ACOs and the shared savings model, Medicaid and Medicare now have a financial incentive to partner with healthcare organizations to deliver better outcomes at lower costs. If done correctly, Medicaid and Medicare stand to save large
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.
Hospital Corporation of America (HCA). Staff Analysis Statement of Problem HCA, after following a conservative financial policy since its establishment, has entered the new decade preparing to make some changes in order to realign their financial strategy and capital structure. Since its establishment, HCA has often been used as a measure for the entire proprietary hospital industry. Is it now time for the market to realign their expectations for the industry as a whole? HCA has target goals that need to be met in order to accomplish milestones in the future.
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.
In the past few years there has been much debate over the Affordable Care Act and its effects on the healthcare industry in the United States. The Affordable Care Act (ACA) “Will ensure that all Americans have access to quality, affordable health care and will create the transformation within the health care system necessary to contain costs” (The patient protection and affordable care act detailed summary, n.a.). However, what these transformations are and how they will affect the healthcare system, specifically primary care physicians are uncertain. Primary care physicians are the cornerstones for patients in the health care system. They act as a liaison between families and specialist physicians. Primary care physicians provide a variety of patient care services that involve multiple skill sets. They are in charge of diagnosing the patient and managing the plan of care. As a result of the newly implemented Affordable Care Act and the current shortage of primary care physicians “The primary care doctor is a rapidly evolving species -- and in the future could become an endangered one” (Okie, 2012).
1. What is the difference between Introduction One of the hottest issues in the United States is the continuously rising trend of health care expenditures. There are heavy debates about the role of government and insurance companies and the possible solutions. However, little can be heard about the experiences and outcomes of the previous attempts that aimed to restrict health spending.