Cost-sharing and medical expenditures also have to do with population health issues with health plan coverage. People want affordable care with good quality for long-sustaining results. It doesn’t mean consumers won’t deal with burden of higher costs when plans change or the amount of health care treatment is steep with high out-of-pocket costs. The policy background illustrates a lot of the health care spending and plan coverage. They aim to shift health care costs from government and insurance companies into households, (Gould, 2013). Increased cost-spending and taxation have been subject to the policy proposals. This is why consumers have to be more informed about health plans and new changes. As policy proposals have been beneficial to …show more content…
This can’t be done without the help of hospitals, administrators, and executives. True integration means aligning physician and hospital goals and giving physicians real decision-making and leadership roles, (Aston, 2013). Hospitals have the advantage to bring in specialists for certain disease specific treatment and procedures. There’s a lot of implementing and decision-making when it comes to choosing physician specialists because the costs and insurance rates are important to consider. The hospital and physician practices in prior decades are not the same today and it’s vital to uphold standards for patient safety, care, and medical costs. As (Medicaid.gov, 2015) states, by contracting with various MCO’s to deliver Medicaid program health care services to their beneficiaries, states can reduce Medicaid program costs and better manage utilization of health services. Most states are implementing and coordinating more traditional services for managed care. Medicaid will to rise and aiding people who live in poverty, but the amount of challenges that lie ahead are problematic. For instance, the types of services including long-term care, mental illness, and eligibility standards are not permissible for everyone. According to (Medicaid.gov, 2015), these benefits are dedicated on improving care for …show more content…
Additionally, few of the many services are preventive, diagnostic, injection, immunizations, medications, health education, counseling, hearing, and vision. Moreover, when a primary care provider signs a tax or capitation agreement, a list of specific services that must be provided to patients is included in the contract, (Alguire, 2015). By gaining young physicians to fulfill these specific types of preventive practices is helpful and a constant need. This is why contract negotiating is so important and this source provides a detailed list of (PMPY), capitation rates, and services. The flipside to capitation rates is the amount of referrals exceeding cost rates which can put managed care facilities in financial turmoil. Without capitation rates, managed care wouldn’t be able to stabilize costs. Capitation rates vary among different ages, categories, and withhold amounts. Also, capitation rates vary region to region so close proximity may be helpful, as opposed to different states further apart. Different rates and withholdings apply even Medicaid for those who are eligible to receive services. Primary care physicians must always be forward-thinkers when it comes to payments, services, hiring specialists, and continuing
This paper will conduct a cost benefit analysis of the three underlying methods that are either used solely or blended together to pay physicians in Ontario. It will compare and contrast Fee for service, capitation, and salary model. This paper will explore the impact of these models on quality and quantity of the primary health care system.
The current health care landscape has been characterized by large scale consolidation and vertical integration of payers and providers. This has led to a handful of dominate players with substantial influence, and an increasing overlap in responsibilities between payers and providers. Although payers and providers have traditionally been on opposing sides, battling each other about quality of care versus cost-effective care, they are shifting to working together to achieve better value.
The Physician/Hospital alignment model is the teamwork between physicians and hospitals to achieve the common goal of providing quality care to patients (med synergies). Physician/hospital alignment opportunities have come into play more predominantly in recent years due to quality, financial, and regulatory aspects of healthcare reform. Physicians and hospitals are more motivated to align now because the new healthcare reform requires an improvement on key aspects such as quality, cost, and efficiency. Moreover, an increase in patient numbers, a decrease in reimbursements, and a shift among new physician goals and values have contributed to the drive for this alignment. Physician/hospital alignment can be characterized in the range of tactical to transformational. Tactical alignments can include joint ventures, co-management agreements, volunteer medical staff, etc.
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.
As more and more people go without any medical insurance, the time for changes in the healthcare industry seems to be now. The government cries for restructuring and the cost coverage of prescription pills should make us step back and question the broad picture. Why would the public benefit from captitation and which segments of the healthcare industry would benefit from which types of capitation? It is important for the public to be educated on our options, healthcare is something that effects us all, old, young, rich, and poor. Why are medical executives determining the directions of cost utilization in the system and not the public? The only thing that seems to be for ceratain is that further research is vitally needed to clarify how capitation truly effects physician-patient relationships, decision making by physicians, and clinical outcomes.
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.
Reimbursement programs are a part of the United States health care system and they represent a financial tool for providing cash flow to service physicians and hospitals. Often times, the competency to provide quality health care is to be contingent on the payment for the services given by physicians and hospitals. Physicians that take part in the managed care systems are reimbursed by several different methods for their services. The two most common methods are Fee-For-Service or Capitation. Managed health care has grown considerably within the health care industry and Physicians have faced several challenges in establishing and financing payment systems for services. On the daily in the news you will see or hear about the financial savings resulting from managed health care as well as the restrictions on patient freedom. Insurance risk seems to be one of the less talked about concerns in the movement toward providing health care and professionals often ponder about who should bear the risk of insurance fees. For providers reimbursement is an essential portion of the managed care system. In order for them to receive their incentives to provide that efficient quality care they need to be reimbursed
The contentious debate about our healthcare system is an epitome of the ongoing political circus in America. With the 2012 elections looming just around the corner, we can expect the vitriol to rise rapidly. Our country spends twice as much on health care per capita compared to other developed countries. The current system is so dysfunctional and projected spending will increase every year, putting an unbelievable strain to our fragile economy. Majority of health care dollars spending are channeled on to patients with chronic illnesses, many of which can be prevented. Unfortunately, medical doctors practicing preventive care are being squeezed out of the equation. The shortage of primary care doctors in America is inevitable because of limited income, lesser prestige, and fewer opportunities.
Managed care is simply a system that delivers health care to a specific population purchased through health insurance plans. Practitioners and providers manage the use of health care services and cost by providing effective diagnosis and treatment, appropriate use of inpatient and outpatients facilities, population-based planning, health promotion and education, and disease prevention. Managed care uses a “gatekeeper” system, where patients or beneficiaries are assigned a Primary Care Physician (PCP), who they see initially for all medical care. The PCP acts as a gatekeeper by initiating referrals to specialists when required and approving inpatient admissions. Managed care was seen across communities in America as early as the 19th century and by 1938, Henry Kaiser had adopted a pre-paid medical plan for his employees. During World War II Kaiser used pre-paid medical programs for his workers and after the war he opened these plans to the public, which became the Kaiser Permanente we know today. Pre-paid healthcare and Health Maintenance Organizations (HMOs) came into full use in the 1970’s when the federal government established grants and loans as part of a health care strategy to provide care for uninsured Americans by increasing the number of HMO, increasing enrollment, and containing the cost of healthcare. Since the 70’s employers have used managed care as a form of high quality low cost insurance for their employees and the federal government has turned to managed care for both Medicare and Medicaid programs.
The federal and state governments are trying to find a way to managed their Medicaid by reducing costs and improving the amount of quality the Medicaid provides. Both federal and state governments are trying to eliminate unnecessary services and rely more on their primary care and the coordination of care. sta...
Over the years, the nation has attempted to improve the country economical struggles with different plans such as healthcare plans which can make our country more beneficial. However, issues that started to affect the company growth are that the Health Care cost are going up, Doctor Shortage, Millions of dollars are wasted for unnecessary care and Medical errors. The US health care system has been spiraling out of control and new to be reform thus our nation can become a successful society.
In conclusion, managed care integrates the functions of financing, insurance, delivery, and payment within an organization. It also exercises formal control over utilization. Managed care is viewed as accepting the lowest competitive bid for services rendered. Today, HMOs and PPOs are the most common and widely used models for managed care. Although managed care is here to stay, it requires revision in some areas. Challenges that are to be faced include double agentry, fidelity, confidentiality, honesty, and vulnerability. With the help and guidance of health information professionals, managed care will continue to escalade and become better for all.
First, 3 to 5% of the population is high risk patients who have “at least one complex illness, multiple comorbidities, and psychosocial problems” that require complex, expensive care. (2013). Managers suggest hospitals provide low-cost intensive care management rather than expensive acute care, and coordinate care with other organizations. (2013). Second, 20 to 30% of the population is rising-risk patients who have multiple risk factors associated with chronic disease that require care to prevent worsening risk. (2013). Managers recommend providers eliminate underlying risk factors rather than simply treat the disease, which would essentially move hospital patients into medical homes for coordinate care. (2013). Third, 70% of the population is low-risk patients who have a well-managed chronic condition or who are healthy seeking “convenient access to the services they need the most.”
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.