The health care industry in the United States is very diverse and dynamic. The continued growth of managed health care is influenced by the economy, the need, and the regulatory regulations set forth on the industry. If one of these forces changes, it can affect the entire group; this causes the managed health care industry to be at the mercy of its roots and the industry’s need for it. What started out as a simple idea has turned into a complex and ever growing industry that is necessary for the health care industry to stay afloat in the world today. The health care system is ever changing and it appears that change is the only constant in the managed care organizations. Despite the constant changes in managed health care and the blurring of types of health care plans, it is important to understand exactly what a particular plan includes. Without this knowledge the managed health care users, may find themselves in a binding situation when they try to use their insurance at certain hospital and other health care organizations. Health maintenance organizations or HMO’s continue to penetrate the market in most market areas in most states. These health maintenance organizations continue to offer an array of different plans with features that vary in their ability to balance cost, access of care, flexibility in health care, and their design of benefits (Kongstvedt, 2001). During the last two decades, managed care had gone from a relatively small part of the health care system to being the mainstream manner in which any employer-insured person obtains their health care. It is hard to pin point an exact definition of managed health care and it is nearly impossible to explain the exact benefits its users will reap, because this type ... ... middle of paper ... ...h care system. By developing different plans, with different costs, and different networks, the insurance industry has been able to make health care available to more patients; by allowing people to receive health care without having to pay the entire bill out of pocket, and the customer is able to reap these benefits for a minimal cost per month. While there may be some critics out there that only view health insurance companies as big business and out to collect their pay, without health insurance most citizens of the Unites States would not be able to afford the care they need. Works Cited Burton,C.V. (2011). Managed health care (a good idea gone wrong). The Burton Report, XI. Retrieved from http://www.burtonreport.com.infhealthcare.managedhlthcare.htm Kongstvedt, P. R. (2007). Essentials of managed health care. Sudbury, Mass: Jones and Bartlett.
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).
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.
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.
Universal health insurance is available to everybody with an option to purchase private insurance coverage (The U.S. Health Care System: An International Perspective, 2014). Approximately 90% of the population uses the national system in which premiums are income based. The system uses 240 private insurers for a non-profit, competitive system. Insurance costs are significantly less than the U.S. due to cost negotiations for medical facilities, appointments, and prescription medications (Sick Around the World, 2008). B. United States Healthcare System Healthcare in the U.S. has recently been affected by implementation of the Affordable Care Act (ACA) of 2010.
Davidson, Stephen M. Still Broken: Understanding the U.S. Health Care System. Stanford, CA: Stanford Business, 2010. Print.
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.
Out of all the industrialized countries in the world, the United States is the only one that doesn’t have a universal health care plan (Yamin 1157). The current health care system in the United States relies on employer-sponsored insurance programs or purchase of individual insurance plans. Employer-sponsored coverage has dropped from roughly 80 percent in 1982 to a little over 60 percent in 2006 (Kinney 809). The government does provide...
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.
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.
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.
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,
Our healthcare system has developed into a burden for most people and has terrible consequences for others. It consists of everyone paying for healthcare as a whole, instead of people paying for themselves. This system of healthcare has burdened the people who take care of themselves and have money, but extends the life of people who do not take care of themselves and live in poverty. This is not pleasant for the one’s who decided to go to school and make well over minimum wage. In turn, they are the individuals who end up paying for the people who decided to make bad decisions in their life that put them in the minimum wage position. Clearly, laws regulate the insurance companies but these regulations do not make any sense to many. Balko explains that, “More and m...
The first side to the health care system is the Single Payer system. Many European countries, and our neighboring country Canada, have this type of system. This system has every citizen put his or her money into a fund that would be controlled by a federal agency. That agency would then pay for the treatment. Private insurance companies would basically be die off. The difference from this and our current health care system...
Managed care is one of the leading form health care in the United States. It has become very popular and many people in the United States have taken advantage of it. There are a few different types of managed care programs: Health Maintenance Organizations or HMOs, Preferred Provider Organizations or PPOs, and Point of Service Plans or POSs. Each one of these types of managed care plans has its pros and cons (Cyrene, 2015). If you would ask a few people what types of insurance they have, they are more than likely going to name off a managed care plan because it is more common to find someone with a managed care plan than not. Managed care has changed the healthcare system in many ways, some for the good and
Healthcare is the maintenance or restoration of health by treatment from trained and licensed professionals (Webster). The American people faced many issues with the way the healthcare system is split up. There are four basic healthcare models the United States usescurrently. First, PBS describes that the Beveridge model, covered/ran by the government, through tax payments. This is the only model used in Great Britain but in America it only covers veterans and soldiers, in Great Britain everyone in the country has coverage by it . Another system model the US takes up is the Bismarck model,it helps people to buy their own health insurance through their employer (Healthcare Economist). Three main countries that use this model are Japan, Switzerland, and Germany whose ex-leader, Chancellor Otto Von Bismarck, created the Bismarck method of health care. Which not only covers 90% of their country but allowsthe rich 10% opt out (Reid&Palfreman). An Americans third model option takes of the ideas of both Beveridge and Bismarck and its name is the National Health Insurance (NHI), which Taiwan operates with. The NHI allows private providers to become a choice even though citizens. These four systems have been used for decades and President Obama has put a bill together to propose a change in America'shealthcare. The Affordable Care Act [Obamacare], will give coverage through employers, help people find their own insurance, or government coverage through Medicare for the elderly, and Medicaid for a 1/3 of others (KFF). Medicaid is offered for those with low income, but only states with governors and legislators who approve for this one actually benefit the KFF (Kaiser family foundation) explained. Those who don't have or want health insuranc...