Introduction
Managed care refers to the approaches and methods designed to reduce the cost of healthcare and leverage financial disbursements in order to improve the quality of healthcare to patients. This refers to a series of services offered by private insurance companies that provide health insurance to patients in the form of fee-for-service and value-based health care system for members of insurance schemes. There are group and individual insurance packages that are offered to members who make regular contributions for healthcare services as and when they are needed. Health insurance has always existed in history. However, the Health Maintenance Organization Act of 1973 gave impetus for the growth of managed care in the United States. It led to the creation of many health maintenance organizations which evolved into various private health benefit programs. The managed care system of the United States has been ran by groups (mainly employers and communities) and individuals who either had deductions or made regular contributions to specific insurance funds. This operated through a fee-for-service process that involved people seeking services from registered healthcare providers and these providers got paid for the specific service enjoyed by individual members from the funds of the managed care provider. This paper posits that managed care provides a better alternative to paying for healthcare and enables people to get improved healthcare to enrich their lifestyles.
Literature Review
This section of the research will review and analyze important literature and materials relating to private insurance and managed care. This will include an evaluation of the role of managed care and how it relates to patients and the forms it takes as well as the benefits and limits and emerging issues. This section will form the foundation for further analysis and discussions that will lead to the basis for the resolving the core thesis statement above.
Roles and Functions of Managed Care
““Managed care” is a term used to describe a system and method designed to control the utilization of health care services”. Managed care is mainly about providing a kind of medical solution that fits a patient’s conditions and financial circumstances. This aims at ensuring that healthcare is painless and effective in every way and form to ensure that patients get the best from medical care alongside the facilities that provide these healthcare services.
The role of managed care is to “perform reviews of medical necessities, gain preauthorization to carry out the necessary treatment, manage the case, and obtain the care from the medically appropriate type of provider”. This is meant to provide a system through which patients are matched with the best provider through various financial incentives and other measures that are seen to be the best approach for gaining a win-win outcome in the management of the health needs of a specific patient.
Managed care in some contexts also refer to a convergence of clinical activities, financial abilities of a facility or a patient and organizational activities. This means that it brings together the interests of different parties and help by providing some kind of preliminary care and evaluation of patients in order to match them up with an appropriate healthcare provider. This way, each member of a healthcare scheme is able to get the best kind of treatment and ways to gain health and remain healthy for a long time to come in order to maintain a high quality of life.
Another angle from which managed care is viewed is that it is to correct the problems in the indemnity market by going beyond the provision of insurance packages and services. Therefore, it seeks to improve patient care by providing integrated delivery systems, and avoiding the problem of overutilization as well as being responsive to customers by providing customer care. Managed care also helps patients by improving medical practice in order to optimize financial resources available for providing health and medical care.
Types of Managed Care Plans
There are numerous managed healthcare plans that exist in the delivery of plans. This includes various plans that link doctors and hospitals as well as healthcare providers in order to keep costs down and ensure that the deductions and resources of patients provide the best and most optimal results to patients. There are various options and levels and this includes:
Health Maintenance Organizations: These are preventive care entities that have a number of health benefits that are presented to clients to ensure they have healthy lifestyles and are not threatened by major diseases and problems. Through this, patients get packages that allow them to meet doctors and practitioners to deal with issues that come up their way from time to time.
Managed Behavioral Healthcare Organizations: These are packages that are meant to provide healthy mental health programs for patients. This is done by providing patients with important care packages that enable them to get payment coverage where patients are required to seek some kind of psychological or psychiatric counseling and guidance.
Preferred Provider Organization: In this system, doctors and medical facilities sign up to accept lower fees from insurers in return for being a part of a PPO network. Through this, their patients can get lower rates for treatment if they stay within the network. However, if they go to other networks for healthcare, they will have to pay the full cost.
High Deductible Plans: These are high deductions that a family or patient is required to pay for. Through this, they have to pay a major premium and then spread the payments over a period of time. Through this, they are able to get overage and benefits when they have medical problems and issues.
Benefits of Managed Care
There are several benefits that come with providing managed care. This ranges from direct health benefits to other financial benefits that a patient stands to gain in the process of receiving and being given healthcare in different ways and forms.
The first and obvious advantage is that managed care provides lower costs of healthcare services to the consumer. This is because when a person signs up to a managed care plan, the cost of paying for healthcare during times of crisis and difficulties is reduced significantly. This is because in absence of managed care, people will only have to pay for healthcare when they are forced to pay for it. This means people will only have to pay for healthcare when they are in a dangerous situation since most rational people will not consider health a priority on their personal budgets. So managed healthcare promotes the quality of healthcare and gets people to pay less for healthcare.
The essence of managed care is that it promotes quality in healthcare delivery. This is fundamentally due to the fact that managed care link patients to the best level of care and as such, they are able to get better processes and healthcare procedures. On the other hand, managed care also provides systems of accreditation which ensures that the quality standards and levels of healthcare facilities are increased and enhanced.
Prescriptions are often cheaper because there are networks and connections that links a patient to a pharmaceutical service. Therefore, every person gaining healthcare can get low-cost medications that will not be so expensive.
Managed care also promotes better planning and helps the consumer to get a more relaxed and disciplined system of spending. This is because healthcare is important and if there is a system of getting people to pay for it though managed care systems, this provides a better opportunity for them to make the best of their incomes and earnings.
Limitations of Managed Care
The downside of managed care is that it restricts people in many ways and forms. This is because most people will want to seek healthcare within the context of the small framework of what they contribute to. This means other forms of healthcare which might be important but not covered by the plan they belong to would be neglected.
There are various requirements for strict approval for most managed care programs. This is because almost every program has a list of approved services and processes that must be followed. And if patients and prospective members cannot get the necessary requirements, they are excluded.
Furthermore, managed care comes with a lot of malpractices amongst practitioners. This means that most practitioners might refer patients to people within their networks. This could lead to poor quality of healthcare delivery and might end up having some rather negative consequences to patients rather than helping them to overcome their medical conditions.
Emerging Issues
The main issue that is worthy of mention is the impact of the Affordable Care Act also known as Obamacare. The essence of the Affordable Care Act is to regulate and remove aspects of profit motives from the delivery of managed care. This is because most hospitals and medical facilities that delivered its services with the profit motive. And due to this, they had practices that were anti-competitive and often detrimental to the consumer.
The essence of the Affordable Care Act is to hold managed care organizations accountable for their members and the services they provide for them. This means they will have to pay a specific amount of money to healthcare facilities and irrespective of the number of people they take care for, they will receive that amount. This is considered to be something that protects consumers and gets healthcare facility providers to work within what providers will give to them.
Discussions
Managed care is about efficiency. It is about convenience. And this is in many ways better than the healthcare services individuals could get on the market if they seek healthcare without being mart of the managed care organization. This process leads to many different opportunities for members.
The quality of life of people increases when they live without health challenges. Without managed care, most people cannot afford to have preventive healthcare. They would live with the view of paying less for healthcare and this would come in the form of paying for health only when they are very sick. This would also get healthcare providers to only deal with the most urgent and pressing cases and hence, have non-competitive actions.
Managed care helps to link people who have specific health requirements to the best and most appropriate healthcare provider. This ensures the optimization of resources and leads to better leverage in the healthcare system.
Conclusion
This study finds that the benefits of managed care far outweighs medical care that is not within such a framework. This indicates that managed care is beneficial in promoting efficiency, giving convenient care, improving health in general and optimizing healthcare resources. The process has some downsides of being strict and rigid. However, the Affordable Care Act seem to resolve it. Although the results of the Act is not fully known yet.
References
Billi, J. E., & Agrawal, G. B. (2013). The Challenge of Regulating Managed Care. Detroit: University of Michigan Press.
Fordney, M. (2016). Insurance Handbook for the Medical Office. St. Louis, MI: Elsevier Health .
Health Coverage Guide. (2015, June 8). Managed Care. Retrieved from http://healthcoverageguide.org/reference-guide/benefits-providers-and-costs/managed-care/
Kongstvedt, P. R. (2012). Essentials of Managed Health Care. New York: Jones and Bartlett.
Navarro, R. (2013). Managed Care Pharmacy Practice. New York: Jones and Bartlett.
Petr, C. (2014). Social Work with Children and Their Families: Pragmatic Foundations. New York: Oxford University Press.
Scanlon, W. (2012). Managed care: state approaches on selected patient protections. Detroit, MI: US General Accounting Office.
Todd, M. (2009). The Managed Care Contracting Handbook, 2nd Edition: Planning & Negotiating. New York: CRC.
