Managed Care: Illness vs. Wellness Based Summary For this paper the assignment was to review both of the demand models of managed care: illness-based versus wellness-based. To initiate an understanding of these models, it is important to have a basic understanding of managed care. An encapsulated definition of managed care is the delivery of health care that is done so in a way that the system provides cost effective care that is delivered within the demand of high quality of services. In the United Sates the current form of managed care is a response to a system in which the controlled cost is a direct response to the purchaser. With principles of a managed health care system that is able to monitor the coordination of all services, places and emphasis on health education, encourages the appropriate care be provided, all in a cost effective manner. This principles have in turn given the consumer the capacity to demand health care services through an “illness based” or “wellness based” delivery system. …show more content…
In this demand model there is a presumption that consumers command a level of quality of care when they are “sick, injured, or otherwise in pain and that physicians are available to these consumers once they become patients,” (Samuels, 2012, p. 16). Therefore, in this model, those that are covered by an insurance is a consumer and does not become a patient until they are in need of care. Samuels’ (2012) describes illness-based demand further by stating that as consumers prior to seeking out healthcare, whether a practitioner’s office, a clinic, urgent care, or hospitals’ emergency room, they progressively become sicker. Prior to the event this consumer has not yet been identified by the system. Illness-based model remains the emergency services
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).
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
In Kingdon’s framework, a problem of interest can be disclosed to the public via a change in indicator (17). In the health care system, the change of indicator is the rise in number of uninsured citizens (Cochran et al, 269). The access to health care is through health insurance, which in most cases is not easily attainable for those of low income (Cochran et al, 269). A person with no insurance is still capable of receiving care, albeit at a reduced quality, and by paying direct costs. This can lead to not receiving proper care from the medical staff, or the diminishing existence of safety net hospitals (Cochran et al, 269; Zwanziger and Khan, 494). Thus, insurance is an important factor in the well-being of citizens to gain access to high quality comprehensive ...
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.
Despite the established health care facilities in the United States, most citizens do not have access to proper medical care. We must appreciate from the very onset that a healthy and strong nation must have a proper health care system. Such a health system should be available and affordable to all. The cost of health services is high. In fact, the ...
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.
Managed care, as it relates to providers healthcare, can be defined as a patient that only sees the doctors and specialists that are in their health plan. In compliance to this agreement, the co pays are lowered by a managing company who oversees all health care interactions of their clients. The reason these costs are kept significantly lowers is because the company has contracts with particular healthcare providers and hospitals. There are three different types of managed care plans that are available. These are Heal Maintenance Organizations (HMO), Preferred Provider Organizations (PPO), and Point of Service plans (POS). Each is a little different from the other, but provide the same basic service, managed health care.
Managed care reimbursement models have contributed to risk avoidance by negotiating discounts, discouraging use, and denying payments for charges that appear to be false. Health care reform has increased awareness to the quality of care providers give, thus shifting the responsibility onto the provider to provide quality care or else be forced to receive reduced reimbursements (Buff & Terrell,
6. The special characteristics of the U.S. health care market are Ethical and equity considerations, asymmetric information, spillover benefits, and third-party payments: insurance. Each one of these characteristics affects health care in some way. For example, ethical and equity considerations affect health care in the way that society does not consider unjust for people to be denied to health care access. Society believes that it is the same thing as not owning a car or a computer. Asymmetric information also gives health care a boost in prices. People who buy health care have no information on what procedures and diagnostics are involved, but on the other hand sellers do. This creates an unusual situation in which the doctor (seller) tells the patient(buyer) what services he or she should consume. It seems like the patient has to buy what the doctor tells him. The topic of spillover benefits also cause a rise in prices. This meaning that immunizations for diseases benefit not only the person who buys it but the whole community as well. It reduces the risk of the whole population getting infected. And the last characteristic is third-party insurance. Which involves all the insurance money people have to pay. This causes a distortion which results in excess consumption of health care services.
Capitation is “a system that paid doctors a set fee from which they had to care for all of their patients, the sick and the well.” (Mark David, 1999) Managed care became in existence and produced changes in the consumer’s roles in the healthcare field it caused a great emphasis on preventive medicine and being accountable for your own health. By the 1990’s communications added more consumer advancements offering information through the World Wide Web. This grew into an alternative medication for most Americans. Computers allowed patients to practice “telemedicine” which is a system that used the Internet so that patients could be diagnosed and sometimes even treated by doctors at a distance.
“Free medical services would encourage patients to practice preventive medicine and inquire about problems early when treatment will be light; currently, patients often avoid.” (Messerli)
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...
The United States health care system is one of the most expensive systems in the world yet it is known as being unorganized and chaotic in comparison to other countries (Barton, 2010). This factor is attributed to numerous characteristics that define what the U.S. system is comprised of. Two of the major indications are imperfect market conditions and the demand for new technology (Barton, 2010). The health care system has been described as a free market in
The cost of US health care has been steadily increasing for many years causing many Americans to face difficult choices between health care and other priorities in their lives. Health economists are bringing to light the tradeoffs which must be considered in every healthcare decision (Getzen, 2013, p. 427). Therefore, efforts must be made to incite change which constrains the cost of health care without creating adverse health consequences. As the medical field becomes more business oriented, there will be more of a shift in focus toward the costs and benefits, which will make medicine more like the rest of the economy (Getzen, 2013, p. 439).