Managed care is an essential system of delivering health care across the country that works towards the provision of a generalized structure necessary to focus on the use, access, effectiveness, quality, and cost of services offered. The management aspect creates a link to the patient, which deliberates on the provider services noted across the industry. Two main modes of managed care provisions include provider reimbursement as well as hospital reimbursement aspects. Working on these aspects requires a premium understanding of issues within the community. Provider networks attempt to reduce costs that emanate from providing better fees for the services they render, an aspect that could be considered ideal in such a situation. Hospital reimbursements happen when hospitals look for favorable fees to reimburse their physicians without getting out of business. When providers reimburse their physicians in such a case, they work towards ensuring that they retain some money for reinvestments to avoid closing their hospitals (Cox, 2010). Eventually, the provider reimbursement method will be considered favorable since the fees they offer are higher compared to what the hospitals offer. The problem is that this may bring out some form of competition and that could affect the costs, process of offering care as well as management of the care offered. Market forces will force more doctors to take up the process, and that could affect the changing management process emerging from the practice patterns presented in such structural demands (Cox, 2010). Fears of changing healthcare delivery system are also rife in such areas, and it is harder meeting these demands as that creates different ventures noted when addressing the need for such competitive demands. Ideally, the capacity in such areas only emerges when seeking to link market level management to manage care organizations.
Different methods of payment were used to address the aspect of reimbursement since managed care organization had a traditional means of doing the same. This traditional method consisted from fee-for-service (FFS) and capitation. For FFS, the compensation of health care providers addresses changes taking place across the community, an aspect that leads to the development of varieties in such areas. Some of the compensations include fee schedules, billed charges, relative value scale, budgeted FFS, mandatory reduction in various fees, as well as individual fee allowances. Capitation was included in many of the traditional reimbursement procedures such as full risk and global capitation (Cox, 2010). Capitation further provided fixed amounts of money to every member on a monthly basis that was paid to caregivers for the services covered rather than the specifics provided. However, changes were made and a bonus system introduced to provide physicians with better retainers. Contact capitation modified this and allowed as many of the specialty physicians to earn more with payment becoming divided into a specific period and within an average noted the cost of care. Hospital reimbursements have been considered as being difficult to capitalize on, an aspect that has led to fears of hospitals closing due to lack of profits (Bundorf et al., 2004). The process makes it harder to appreciate such concerns and even makes it easier to shift a different angle of viewing the hospital utilization structures within the community.
Different entities have come up with different payment methods to ensure that they can retain the best services from their providers. The physicians have been working with various consultative measures to allow them to work on the reimbursement methods that will define their changing demands. Ideally, the system that works best is one that enhances the contact systems in place and utilizes some of the payment structures to boost physician motivation (Bundorf et al., 2004). Capitation seemed to be a better way of dealing with the management of patients at all levels. Providers who have a specialty clause gain much more and have an easier time convincing specialized physicians into buying this idea. The main problem is that the management of care provides more opportunities for physicians to gain some form of idealized capitation so as to develop some form of satisfaction and drive care as expected. Care providers have further managed to take into consideration the collection of data to enhance the provision of services, an aspect that proves quite effective when addressing such negotiations and working on available network sessions. Financial incentives have further been found to induce some form of working mentality that seems to favor the increase of quality care in a timely manner (Cox, 2010). Provider reimbursement, as opposed to hospital reimbursement models, seems to get better at addressing attempts to improve relationships, an aspect that brought out the intended changes and health plans that assist in such risky maneuvers.
With the PPACA legislated, new methods are needed to meet the demands of the managed care organizations. Health centers currently expect the presence of more patients since the act expands coverage to more individuals. Medical homes have been considered as an important part of the payment structures presented (Bundorf et al., 2004). Modes used in this case consider primary care payment based on the focus on the coordination of care and tracking of the health development in an area. The use of bundled payments has been discussed too where an episode of care has been considered as an alternative. Shared savings have also been used in different programs that assist in the collaboration of payment models and rewarding physician groups so as to reduce overall spending (Cox, 2010). Certainly, this allows for easier development of new measures to assure physicians of their fees. The equations used must reflect on the pay models in questions because the patients will require a simple way of handling the new network models. Ultimately, dealing with new information requires an understanding of the changing market forces.
References
Bundorf, M K. et al. (2004). The impact of managed care on the treatment, costs, and outcomes of fee-for-service medicare patients with acute myocardial infarction. Health Serv Res. 39(1): 131–152.
Cox, T. (2010). Legal and ethical implications of healthcare provider insurance risk assumption. JONAS Healthcare Law, Ethics, and Regulation. 12(4): 106–16.
