Introduction The concept of Health Insurance and managed health care the inventions of the twentieth century that were started as prepaid health care. The early insurance concept was merely a way for people to pay medical bills not a way of protecting individual financial assets as the case is today. Overall the health care industry has endured significant changes since its inception. The early years of Managed care (1910 to mid-1940) The hallmark of this era was the emergence of the prepaid practices and the emergence of the Blue Cross and Blue Shield (the Blue Cross and Blue shield were commonly referred to as the blues). It was noted that most hospital physicians continued to retain the Blues until 1970‘s (Kongstvedt, 2009). The pre-world …show more content…
These early HMOs included the Kaiser Foundation Health Plan, the Health Association in Washington, D.C. Unfortunately, this era also witnessed tumor in the medical community as the American Medical Association (AMA) greatly opposed the prepaid plans of the early 1900s while favoring the indemnity- type insurance that reimbursed policyholders. Therefore with the pioneers of prepaid services encountering daring degrees of oppositions, a strategy to discourage such opposition led to the development of the early Independent practice associations (IPA) model HMO (Fox & Kongstvedt, 2015; Kongstvedt, 2009). Early Years of Managed Care: 1940’s to mid-1960s This era witnessed the expansion of the health benefits. Prior to world war II, only 10% employed individuals had health benefits but, by 1955 the number had increased to 70 %. For example, the health insurance plan of York was created solely for the employees of New York …show more content…
The early parts of this era also, witness the credentialing requirements of the various HMOs across the nation. For example state licensures were mandatory while federal qualifications were regarded as a voluntary act by the HMOs, however, it was in the best interest of the HMO’s to obtaining the approval of the federal government (Fox & Kongstvedt, 2015; Kongstvedt,
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.
The strategic plan for 2015 led to a membership growth of 650,000 members. The main internal driver for the astounding growth, being managed care offered at 20% to 25% less than the surrounding competitors (Brooking Institution, 2015). The more membership growth the more profitable Kaiser becomes based managed care system. Kaiser Permanente’s growth can be related to high scores amongst CMS and it’s highly recommended operation structure amongst the healthcare industry. According to the CMS “2016 Star Ratings Fact Sheet,” Kaiser Permanente represents five of 12 medicare health plans (with Parts C and D) that earned 5 stars — and of the 1.6 million beneficiaries enrolled in those 5-star plans nationwide, 81 percent are Kaiser Permanente Medicare members (Kaiser press release). The Kaiser Permanente Medicare plans since 2009 have always been operating at a high performance
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...
Many pivotal events over the last century have brought our healthcare system to where it is today. Some were indirect, such as World War II (and how it led to direct events such as medical advances that shifted focus from critical care and managing contagion to preventive medicine and health insurance as an employee benefit) and the internet (which has provided a wealth of tools and resources that were once only available to healthcare providers and has served to foster technological advancements such as Electronic Health Records and telemedicine). Others were targeted interventions, such as the Hill-Burton Act, which was enacted in 1946 and provided infrastructure dollars to healthcare facilities that agreed to provide a significant volume of free or reduced cost services to those with limited ability to pay (HRSA, 2014). Perhaps the most influential targeted event was the passage of Medicare and Medicaid programs, which was the point at which the government became the administrator for insurance programs for the poor, creating a system that would continuously grow and impact service delivery through regulatory control.
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 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.
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.
The American Medical Student Association (2004) stated that ?Between 1945 and 1970, America?s economy was strong and booming?, they owned about 60% of the world profit.? (¶13). During this time employers were able to cover their employees and the employers were also able to ?write off the health insurance as tax-deductibles for the company.?(AMSA, 2004, ¶ 11 ). As time progressed our economy began to unravel.
Employee health benefit plans flourished in the 1940’s and 1950’s. Unions bargained for better benefits, which included tax-free, employer-paid health insurance. When war hit between 1939 and 1945, government froze wages which led to an increase of group health care. Since employers were unable to attract employees with higher wages, employers decided to improve their benefits package by adding health care coverage. Gove...
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,
Health Care workers are constantly faced with legal and ethical issues every day during the course of their work. It is important that the health care workers have a clear understanding of these legal and ethical issues that they will face (1). In the case study analysed key legal and ethical issues arise during the initial decision-making of the incident, when the second ambulance crew arrived, throughout the treatment and during the transfer of patient to the hospital. The ethical issues in this case can be described as what the paramedic believes is the right thing to do for the patient and the legal issues control what the law describes that the paramedic should do in this situation (2, 3). It is therefore important that paramedics also
An HMO is an organized health care delivery system, which provides health care to its members through networks of doctors and hospitals. Rather than traditional health plans, HMO’s cost less. Two ways HMO’s control costs are: controlling hospital admission and length of stay, and by providing incentives to physicians. These two cost control methods are further examined by an article published by The National Bureau of Economic Research (2002). The article examines the incentives to physician strategy for reducing utilization cost. The Physician Guide to Managed Care (1994) describes HMOs the case management procedures used to control cost through hospital length of stay and admissions.
retrospect to its governing authority (Shi & Singh, 2012). However, private and public agencies are the controlling constituent in today’s business. Free markets allow patients to choose providers without the prior approval of insurance companies. The current system offers a proposed plan of limited physicians in exchange for payment of services. Because the potential has been given to the payers, they regulate the cost of services rendered through contractual
Health maintenance organizations (HMO) are organizations that provide or organize health insurance, self-funded health care benefits plans, individuals, and other entities for the United States as a liaison with health providers or hospitals on a prepaid basis. In this simulation a virtual organization Castor Collins Health Plans presented three HMO options to two organizations. I will review one of the company’s demographics, discuss the HMO choices, explain the differences in the choices presented, and why I chose the plan I chose.
Many people are concerned about rising health care costs. In reaction to this, some individuals and companies are gravitating toward the assumed lower prices of Health Maintenance Organization (HMO) health plans. HMOs spend billions of dollars each year advertising their low cost services. While these savings look good on paper, there are many pages of small print. The explanation after the asterisk indicates that not only do the HMOs lack lower costs, but they also short-change the patient in quality care. Much of the money spent on premiums goes directly into the pockets of stockholders and less is then available for