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Pros and cons of managed care delivery
Pros and cons of managed care delivery
Pros and cons of managed care delivery
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As described in the Health Care in the United States textbook and notes, managed care services are delivered through organizations, better known as MCO (Managed Care Organizations). MCO’s are a category of insurance company – main way health insurance is delivered – that guarantees a member’s health care will be provided. The key functions of insurance, such as funding, distribution/delivery, and payments are taken over and overseen by MCO’s. This means MCO’s control quantity and reimbursement, resulting in cutting costs. One specific way managed care attempts to control costs is by gatekeeping. Gatekeeping is fundamentally a patient needs a referral from his primary physician to see any other specialist inside their network. Making referrals necessary helps cut the cost immensely. For example, a patient cannot make an appointment to see a …show more content…
If the patient’s primary physician believes seeing a neurologist is needed the the physician can refer the patient to a neurologist.
I believe that gatekeeping could successful in the U.S. health care system; however, I believe more often then not, there will be situations that prevent the successful outcome. Money is saved with gatekeeping. If the patient used in the prior example didn’t really need to see a neurologist, he only needed some medicine for his headaches, then he saved the insurance company money. The health cost is considerably less because a primary physician (general) cost a lot less than a neurologists (specialist). National views of health care justice in the United States includes good quality of life. As discussed in the textbook, American’s
health care, only those who are “privileged” enough to afford health care can receive it. So is this what health care in the United States is and should be?Arnold Schwarzenegger the former Governor of California stated “Health care is not a right, but its cause is a government interference in the healthcare system. The solution is to leave doctors, patients and insurance companies free to deal with each other on whatever terms they choose, not to socialize American medicine” (Russo). Schwarzenegger then went on about how this would cost the government too much money and that this is not the answer to the healthcare improvement (Russo). Sen. Shelia Keuhl, the senator that wrote the bill stated in a press release “It’s important to understand that vetoes of health reform legislation have very serious consequences […] Because of these vetoes, there will continue to be very little regulation of the runaway health insurance market and no protections for consumers”
First, he uses an analogy fallacy, he is comparing the healthcare industry to Starbucks. Stone even creates this into a syndrome when he states, “They expect their CT scans, when they want them, in much the same way they expect their decaf caramel extra hot low-fat macchiato. Think of it as the Starbucks syndrome in healthcare,” in order to explain his analogy. The author also establishes the appeal of everyone living in California as huge snobs. This leads into his second fallacy, when he uses a generalization fallacy, he assumes that all Californians expects everything to run how a Starbucks runs. Starbucks is known to be quick, and efficient, and Stone goes back to the first ethical example involving the premature ordering of the MRI scan when he states, “The doctor saved time and avoided a difficult discussion by going along. The patient saved a trip and got what she wanted. Just as she would have at Starbucks,” to provide how patients want their doctors to be how their baristas would be at Starbucks. Although, Stone uses these two fallacies as part of his strategy it help persuade the readers by using a relatable experience that we have all had, a trip to
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).
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
The facts bear out the conclusion that the way healthcare in this country is distributed is flawed. It causes us to lose money, productivity, and unjustly leaves too many people struggling for what Thomas Jefferson realized was fundamental. Among industrialized countries, America holds the unique position of not having any form of universal health care. This should lead Americans to ask why the health of its citizens is “less equal” than the health of a European.
Providers must act in the best interest of the patient and their basic obligation is to do no harm and work for the public’s wellbeing. A physician shall always keep in mind the obligation of preserving human life. Providers must communicate full, accurate and unbiased information so patients can make informed decisions about their health care. As a result of their recommendations, providers are responsible for generating costs in health care but do not generate the need for those expenses. Every hospital has both an ethical as well as a legal responsibility to provide care, even if the care may be uncompensated.
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 a neurologist I am a medical doctor with specialized training in diagnosing, treating, and managing disorders of the brain and nervous system, including diagnosis of brain tumors. As a professional I act as the primary care provider for patients with chronic neurological problems and as a consultant to other physicians who have clients suspected of having a condition involving the nervous system (Life NPH, n.d.). A neurological examination allows me to effectively diagnose the condition of the patient and suggest appropriate treatment options. I first review the patient's health history with special attention to the current condition.
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.
This procedure would have been of no benefit to the patient so the principle beneficence was not followed. The new doctor at the practice brought to the other doctors’ attention that this procedure was outrageous and would be of no good to the patient or the family. After consideration the other doctors realized they were too emotionally attached to deny the patient of her wish, so they needed to tell her the procedure was canceled. And this is where paternalism comes into play. Paternalism is when a doctor has to put a foot down when a patient is demanding a procedure that is more harmful to them than good (the patient just can’t see it). Doctors are always in the best interest for the patient expect for when paternalism is involved. Sometimes even though a patient is proven mentally competent a doctor has to do what they feel is the right thing to do for the patient even if is overruling the patients decisions. A way to of having benefited the cancer patients of having a baby possibly could have been just taking her to visit some babies to get the feel of what it could be like to be a mothers not actually giving her one of her own to be raised without a mother. Nonmaleficence is a principle that assures a procedure or decision is doing no harm to 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.
Overall, the healthcare system in the United States is still broken because not everyone is insured and disparities are still evident. More policy evolution is required if the US is going to be a nation state that has completely equal citizens. Health scholars must research more so that they can influence what happens in health policy. I believe the patient’s opinion needs to be included so the system
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,
Physicians has been assigned as gatekeeper on healthcare services. A gatekeeper is defining as point of entry each time care is needed for a health problem. Gatekeeping by physician has been discussed and some agreed and disagreed into the system. The three types of argument involved in the necessity for gatekeeping includes, the patients appropriate care received by patient, budget restrain or cost containment, and justice for equal distribution of care to the public. The overusing of health care system and resources is the focus of gatekeeping. Some contested the gatekeeping role of the physicians. The individualized care an individual’s decision regarding when, how and what to receive health care were expressed as the provider and public
patient care. In addition, the main clinical decisions are made not by doctors, but by a board of directors more interested in the bottom line than in little Jennie's cough. When the facts are considered, HMOs should not be permitted to assume the role of the primary medical care-givers.