...Managed Care Lucille Purry Economics of Healthcare Faculty Sever South University 10 December 2013 Abstract Managed care, a deliver system for health care intended to reduce the cost of that care. Examples of managed care organizations are HMO, IPA, PPO, POS and PFFS. MCO’s operate through contractual agreements that are set to meet certain standards due to the fact that they don’t have direct control. Managed care provider and hospital reimbursement ranges from fee for service and capitation. Episode-of-care is where providers receive one lump sum for all the services they provide related to a condition or disease, and capitation is where the third party payer reimburses providers a fixed amount for a period. There are many other forms of reimbursement between these two methods and vary depending on service. Risk – based payment applies to both hospitals and providers. With so many choices in health care coverage and means of payments, it becomes necessary to be sure you have a complete understanding of what is expected from you, what is covered and not covered and to be sure any treatment is necessary. Along with managed care, we have to consider how this affects Medicare and Medicaid. These have changed the healthcare system and joined together to better serve the public. Managed care; advantages and disadvantages as well as how it came to be are to follow. Managed Health Care dates as far back as 1910; one example is when the Western Clinic in Tacoma, Washington...
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...1. Identify 8 managed care contracting terms: a. Administrative services only (ASO): Usually associated with self-funded groups, this is when an insurance company, HMO, or third-party administrator provides claims-processing services, but the employer pays the claim costs. Administrative services usually include billing, enrollment, and coordination of benefits, payment check processing, subrogation, fraud investigation, and network rental. b. Coordination of benefits (COB): Provision regulating payments when a person is covered by more than one healthcare policy. For example, if an employee is covered under a group plan and also under a spouse’s plan, the companies will coordinate payment of benefits so that each company pays the correct portion of the charges and doesn’t reimburse the claimant for more than the cost of the medical care. c. Cost sharing: A broad term representing the ways in which a covered member shares in the cost of healthcare services with the health plan. Examples of this include deductibles, co-payments, and coinsurance. d. Exclusive provider organization (EPO): A term used to describe a health plan that is similar to an HMO in that it provides benefits only if the insured uses the specified network of providers, but is usually offered as an insured or self-funded product. EPOs usually mandates that coverage be channeled through a primary care physician. Also, EPOs is governed by the state’s Department of Insurance, as are PPOs...
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...In recent years the number of Americans receiving health care services through some sort of managed care organization has increased greatly. It’s important to know the difference between the different plans. An indemnity plan was the first type of health insurance. There is no network of providers, meaning the insured can go to any doctor or hospital and there are no co-pays. As an insured with a $500 deductible, the insured would pay the first $500 of any charges. Then they would go into the coinsurance period where both the insured and the insurance company are paying, i.e. 80/20 for typically $5000 to $10,000, costing them around another $1000 to $2000. After that, the insurance company pays everything up to the limit of the policy. There is always an indemnity plan attached to every POS and PPO plan. The advantage to and indemnity plan is that coverage remains the same for any doctor seen and it is ideal in rural areas where there are limited or no PPO or HMO networks. There are disadvantages of course, like any plan. The cost of and indemnity plan is usually much higher than a PPO plan because cost savings are not negotiated with the providers. A PPO almost always has a deductible, and coinsurance. If you stay within the network, there are also co-pays for certain services where the deductible and coinsurance do not come into play. For example, an office visit might be a $15-$40 co pay without regard to a deductible or coinsurance. For a hospital stay, you would be...
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...MEMORANDUM ON MANAGED CARE TO: Dr. Forney Fleming and the Class of Fall’14 for American Healthcare System FROM: Iyappan Somasundaram DATE: September 10, 2014 RE: Managed Care, Markets and Rationing Briefing Paper MANAGED CARE: An organized way to deliver healthcare services by efficiently utilizing healthcare resources to provide quality patient care. Managed care principles have been used for over 100 years in the U.S. The major goals of managed care include improving quality and accessibility of health care, improving outcomes and overall quality of life for patients and containing costs. The growth of managed care in the U.S. was spurred by the enactment of the Health Maintenance Organization Act of 1973. The organizations that use the above techniques or provide them are called “MCO” or “Managed Care Organizations”. Managed Care organizations are broadly classified into two categories viz. HMO, PPO & POS. During the last quarter of the 20th century, HMOs emerged as an important alternative to traditional medical indemnity insurance plans, and largely supplanted them. This was largely known as the “managed care revolution”. HMOs have had a profound effect on every aspect of the practice of medicine-professional, scientific, social, economic, and legal. HMO (Healthcare Maintenance Organizations): HMOs are comprehensive health care delivery systems that offers a wide range of healthcare services through a network of providers who agree to supply services...
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...Managed care is a system for organizing the delivery of health services so that the cost of care is reduced and the quality of care is maintained or improved. The different types of managed care include health maintenance organizations, preferred provider organizations, gatekeeper PPOs, exclusive provider organizations, provider hospital organizations, and management service organizations. Health maintenance organizations are one of the most common forms of managed car. HMOs provide coverage both the coverage for care and the care itself. Preferred provider organizations are the second most common managed care alternative. In PPOs the insurance carriers contacts with the providers to provide services at a contracted rate. Exclusive provider organizations are a much smaller PPO. The patient must select a primary care provider and can use only those providers who are a part of the network or who are referred by the primary care provider. Provider hospital organizations are an organization of providers and hospitals that band together for the purpose of obtaining contracts from payer organizations. Management service organization is a separate corporation set up to provide management services to a medical group for a fee. The membership card should include the patients name and will contain a record number or other means of identifying the patient. There will be a magnetic strip on the back of the card that will have additional information encoded on it. The...
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...An Analysis of Managed Care Name: Institution: Medical costs progressively consume a large part of the Gross Domestic Product of the United States. Various sectors that seek health services including the government are increasingly turning to a regulated form of financing and delivery of health services termed as managed care. All citizen in the United States is eligible for this form of care whose purpose is to make medical care accessible for all. This paper seeks to provide a thorough analysis of managed care detailing its role in the transformation of health services, its impact on various heath aspects including access, delivery of care and financing as well as the role of managed care in promoting costs. Exploration of Managed Care Managed Care involves a system of medical provision in which patients choose preferred doctors and hospitals to visit when in need of health services and the cost of treatment is monitored by a managing company. Managed care is key to the control of health care costs that focuses on preventive care to lower cost associated with curative care. Manage Care has three forms. They are Health Maintenance Organizations (HMO), Point of Service (POS), and Preferred Provider Organizations (PPO). Managed care strategies offer financial incentives to members who control their own health care expenses for instance through the lowering the prices of prescribed drugs (Shortell, Gillies, and Anderson, 1994). Health Maintenance...
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...Managed Care and the Effects on Health Care Today By Wendy Araiza HCS/531 Health Care Organizations and Delivery Systems Instructor Rochelle Robinson-Levant 1/28/2014 Managed care refers to a variety of techniques for influencing the clinical behavior of health care providers and/or patients, often by integrating the payment and delivery of health care. Managed care is a system of health care delivery that employs mechanisms to manage and control utilization of medical services, and seeks to achieve efficiency by integrating the basic functions of health care delivery, and determines the price at which the services are purchased and, consequently, how much the providers get paid. Managed care is the most dominant of all the health care delivery systems in the United States and available to most Americans” (Si, L. 2012) The overall aim of managed care is to place administrative control over cost of, quality of, or access to health care services in a specific population of covered enrollments. "An increasing number of managed care organizations (MCOs) and integrated networks now provide a continuum of care, covering many of the service components." (Shi, L. 2001) Managed health care in relation to changes in health care includes a variety of incentives to encourage the practice of cost-effective medicine, and to minimize variation in clinical practice patterns. Managed care may increase pressure to handle more with less; for example, less costly medicines...
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...Managed care has had a significant event that has affected health care today. According to Mirriam-Webster dictionary, the definition of managed care "is a system of health care that controls costs by placing limits on physicians' fees and by restricting the patient's choice of physician". Simply stated, managed care provides benefits to those who cannot afford the expenses of an insurance plan. Managed health care is considered to be a process by which medical benefits are monitored for the purpose of cost management, which results in the ability to limit the access to health care benefits and coverages. The health care system in the United States is an emerging system that is constantly being transformed. Our current health care system today is very different from what was established in the past years. These changes are a reflection of what the patient's want, which was to move from an indemnity plan to a managed health care system. There are various reasons for the changes within the system, but primarily due to economic realities. The cost of healthcare is constantly increasing and has grown faster than any other economic sector. Population growth, increased pharmaceutical necessity and health cost increases are just a few key factors that are the driving force of such rapid growth. HMO, Health Maintenance Organizations, are defined as "a prepaid health maintenance organization that delivers care to its members via designated physicians and requiring members ...
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...While managed care can be beneficial for most parties, it can also be a nightmare for a healthcare provider. The idea behind managed care is that the managed care network is in charge of the rates and the networks in which the recipient of the insurance policy can receive care (Medline Plus, 2014). This can sometimes mean that healthcare is not the full focus and that the care system is more of a business which can lead to complications for the provider (Welch, n.d). Managed care is a multi-faceted and complicated system. At its very barest and basic definition it is “a healthcare plan or system that seeks to control medical coast by contracting with a network of providers” (Dictionary, 2015). This means that the network providers control...
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...Chris Murphy Assignment One – ECN 360 Health care over the past few decades has made tremendous leaps and bounds with respect to screening, treatment, and many other aspects. However, recently there have been debates about whether or not people in the US are receiving ‘too much’ health care. One might ask what qualifies someone to be receiving ‘too much’ health care. There are many alternatives for every single treatment regimen, surgery, or other action that would combat an illness, that aren’t always relayed or discussed with the patient at hand. Today, insurance policies can cover a varied range or services for a consumer. Primarily, when a patient is discussing a treatment with their physician, their main concern is if that specific treatment is covered under their insurance policy, and if not, what are its costs associated with it. Since physicians make more off of a treatment that costs more, they generally are biased towards a treatment that, in turn, will increase their wealth. With this being said, health specialists are now encouraging patients to ask in-depth and extensive questions regarding the actions they are about to take to combat their illness. Questions like: What do I get out of this treatment, Why this certain test, What are my chances of something bad happening if I do/don’t get this specific test, as well as asking what their other options are. This way, patients will better understand their options and be able to make a decision that coincides...
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...Managed Care is bad for healthcare providers. Managed Care is a huge part of health care today, but is it the answer in controlling health care costs? Managed care plans were originally credited in the 1940’s as non-profit organizations and it wasn’t until the 1970’s and 1980’s when healthcare costs soared that employers saw this as an alternative approach. But are Managed Care Organizations (MCOs) the best solution for healthcare providers? Many say, “no.” According the American Medical Association, “late payment of claims by managed care organizations (MCOs) and other payers is a common problem for many physicians in a wide range of practice settings, and combating this problem is a priority for the AMA.” There is also a heavy administrative burden on physicians and their staff who often spend excessive time on the phone with MCO’s pursuing unpaid and overdue claims, it is not unheard of for some claims to be outstanding for six months or more. “Managed care plans receive a predetermined amount of money per member, regardless of the service.” (Baker, 2011, p. 35). A clinical perspective of why Managed care is bad for healthcare providers at times is MCOs across the country have taken control of medical decision making by blurring the definition of medical necessity-a clinical determination with covered services-a business determination. At the same time, MCOs specifically disclaim any responsibility for medical decision making and seek to place all liability...
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...Managed Care and Case Management Care Marvin Lloyd BSHS/402-Case Management 27 August 2012 Virgil Miller Managed Care are techniques employed to help reduce the cost for providing health benefits and a system for improving organizations quality of care. The United States National Library of Medicine describes managed care as, “programs that are intended to reduce unnecessary health care costs through a variety of mechanisms, including: economic incentives for physicians and patients to select less costly forms of care; programs for reviewing the medical necessity of specific services; increased beneficiary cost sharing; controls on inpatient admissions and lengths of stay; the establishment of cost-sharing incentives for outpatient surgery; selective contracting with health care providers; and the intensive management of high-cost health care cases” (National Library of Medicine). Manage care has presented many issues for social service workers that include ethical responsibilities to the clients. These ethical responsibilities include self-determination, informed consent, competence, conflicts of interest, privacy and confidentiality, and the interruption and termination of services (Apgar, 2000). Manage care companies may attempt to contain cost by limiting the types and length of...
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...Impact Paper: Development of Managed Care National American University Emily Gregg March 20, 2016 Impact Paper: Development of Managed Care In the early years of healthcare, everything was different. Prepaid medical group practices were created to assure that the clinic had patients regularly, and money coming in. It was the first example of modern capitation, which is a payment per patient per period instead of a fee for service that was previously the standard. This was the early years of managed care. The field has come a long way. Prepaid medical plans became known as insurance, and now there is a variety of them. The aspects that influenced their creation will be discussed, as well as some perspectives between different parties within the field. Some issues have had a large influence on doctor-patient relationship. According to Peter Kongstvedt, some of the issues that impacted the previously stated relationship include cost containment, the development of Managed Care Organizations (MCO) such as Health Maintenance Organizations (HMO), Point of Service plans(POS), and Preferred Provider Organizations (PPO), and the pressures that these MCO’s placed upon the Primary Care Provider (PCP). Prior to MCO’s the provider physician had a main goal which was to manage the patient’s care. In the new MCO plans, the PCP had a new job, a sort of Gate-keeper status between the patient and his or her ability to obtain care that was of higher specialty and cost. The...
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...Health insurance is a contract between a people or group that says the health insurance company will pay a portion of the medical expenses when the individual accesses the healthcare system for the illness, injuries or routine care. The amount the insurance company pays depends on the coverage and varies greatly between companies and policies. A few of the top managed care organizations are Aetna, Humana and United Health Group. These insurance companies offer health insurance, dental, vision, pharmaceutical, Medicare, Medicaid and some even offer disability, life insurance, and pet insurance. All of these companies offer similar plans and services but vary greatly in price. Price per plan can vary depending on the health of the individual on the plan and how many people are on the plan. Employers typically purchase Group Insurance because they can receive a more discounted rate than individual rate insurance plans. Monthly insurance costs are hard to determine. With just a basic quote for a healthy individual between 21 and 30 there is still a huge variation. Aetna is not available in my area, but they are contracted with CoventryOne. CoventryOne has basic plans that vary anywhere from $42.82 a month to $338.87. Humana doesn’t have such a vast price difference and varies between $219.70 -$258.53 per month. United Health Group ranges from $250.65 -$452.34. These prices are all for very similar plans, which makes it hard to choose which one to go with. There are very subtle...
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...What effect do you feel this issue has on people and their ability to receive care? Include suggestions to correct the issues chosen. In order to alleviate administrative liabilities numerous doctors are looking for jobs with hospital facility frameworks for money security instead of private practices. Be that as it may, expanded consolidation might conceivably prompt monopolistic concerns, raise expense of treatment, and diminish the capability and competitiveness of single/private practice. The non-clinical staff has no knowledge of clinical processes and they are obstructing/delaying the patient's treatment because the regulations restrict a specialist's capacity to practice autonomous medical judgments. These regulations should be changed and ought to incorporate clinical personnel who know. The PPACA will present more than 30 million new patients to the U.S. health services framework, a condition that has impressive ramifications with respect to patient access to care and doctor deficiencies. One recommendation would be to utilize Nurse Practitioners (NPs) in light of the fact that they can...
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