Managed care is a term used in the US to refer to various techniques aimed at reducing the cost incurred in the provision of healthcare as well as improving the quality of healthcare. Managed care can also be used to describe the systems of delivering and financing healthcare. The organizations involved in healthcare provision are the main users of the managed care. Managed care enables the healthcare organizations to reduce health costs that are unnecessary (Marcille, 2003).
Managed care use several contracting terms to enable the effective delivery of healthcare to patients. Some of these managed care contracting terms include access; accountable health plan; admission certification; beneficiary; case management; community rating; cost sharing; and emergency. These contracting terms and their impact on healthcare delivery are explained below.
Access: this refers to the ability of the patient to receive medical care. Access to medical aid is affected by factors such as location; cost of health services; time; patient’s consent; and availability of health care services (MCR, 2016). Access is important because it can make a difference between life and death.
Accountable health plan (AHP): this is a combined practice between institutions and practitioners. The healthcare providers and the physicians contract or work with health plans (MCR, 2016). The AHP ensures financing and delivery of a healthcare service in a manner that demonstrates accountability.
Admission certification: this method ensures that admission of patients is done to only those patients that require hospital care. Certification is given immediately after admission or before admission. The period that the patient will stay in the hospital is also assigned when admitting the patient. Admission certification prevents unnecessary hospital stays (MCR, 2016).
Community rating: this is a system that fixes payment rates on the basis of per family or per individual. The payment rate varies based on the number of dependants within a family, but is equal for all families or persons within similar compositions (MCR, 2016). Community rating enables equal spreading of costs among the subscribers.
Cost sharing: refers to a financial arrangement where a patient pays cash to receive health care. It also refers to a situation where an insured person pays part of the monthly premium to a health care insurance.
Emergency: this refers to the sudden occurrence of an injury or illness that requires immediate attention or care by a physician. An emergency can enable a patient to be admitted without obtaining certification prior to admission.
Ten years ago, managed care in the US was receiving a lot of negative feedback from patients. There were complaints that the cost control efforts made by the health providers were reducing the quality of care given to the patients (Marcille, 2003). People argued that the healthcare providers were keener on cutting costs rather than providing quality health care. The doctors spent less time with patients and it was hard for patients to see specialists. Today managed care has evolved to allow patients to see specialists when they are very sick. Managed care has incorporated mechanisms that allow for the improvement of the quality of healthcare services.
The future of managed care looks bleak because the insurers are coming up with health plans that restrict patients on the choice of hospitals and doctors (Mathews, 2012). That will mean that patients may delay in receiving healthcare services if they cannot get immediate access to the hospitals or doctors in their health plans. Some people may die as they await the delivery of health care. The insurers may erect more obstacles for patients who need health care services due to the constant pressure of cost reduction.
References
MCR, (2016). Managed Care Terms and Definitions. MCR. Retrieved from: http://www.mcres.com/mcrdef.htm
Marcille, J., (2003). Flashback: Ten Years Ago, Measuring Patient Satisfaction was the Next Big Thing. Managed Care. Retrieved from: http://www.managedcaremag.com/archives/2003/9/flashback-ten-years-ago-measuring-patient-satisfaction-was-next-big-thing
Mathews A. W., (2012, Aug 2). Remember Managed Care: It’s Quietly Coming Back. The Wall Street Journal. Retrieved from: http://www.wsj.com/articles/SB10000872396390444840104577552823507551472
