Chapter 22 Managed Care And National Health Insurance Learni ✓ Solved

Chapter 22 Managed Care & National Health Insurance Learning Objectives

Describe the common models of managed care organizations. Describe the purpose and process of utilization review. Describe the purpose & various titles of the Patient Protection and Affordable Care Act of 2010 (PPACA). Describe the various court rulings involving PPACA. Managed Care Process of structuring or restructuring the healthcare system in terms of financing, purchasing, delivering, measuring, & documenting broad range of healthcare services & products.

Constraints of Managed Care Organizations include limitations on the choice of providers by the consumer and requirements for prior authorization to obtain services. Common Managed Care Models encompass Health Maintenance Organizations (HMOs), Preferred Provider Organizations (PPOs), Exclusive Provider Organizations, Point of Service Plans, Experience-Rated HMOs, Specialty HMOs, Independent Practice Associations, Group Practice, Group Practice Without Walls, Physician Hospital Organizations, Medical Foundations, Management Services Organizations, Vertically Integrated Delivery Systems, Horizontal Consolidations, and Federally Qualified HMOs. State laws, case management firms, and third-party administrators also influence managed care.

The process of utilization review includes prospective, concurrent, and retrospective reviews, aimed at managing healthcare utilization to ensure appropriate care. Managed care organizations also face legal considerations related to liability, employee retirement insurance, and reducing exposure to liability, including acts such as the Healthcare Quality Improvement Act (1986) and the Ethics in Patient Referral Act (1989). Legal actions in managed care involve financial incentives, disclosure, benefit denials, and anti-competitive practices like price fixing.

Market power considerations include product and geographic markets, provider exclusion, and market share concerns under antitrust laws. The Patient Protection and Affordable Care Act (PPACA), enacted by Congress in 2010, aims to increase health insurance coverage, reduce costs, eliminate discrimination based on preexisting conditions, and implement reforms such as coverage of preventive services, extending dependent coverage, and establishing insurance marketplaces. PPACA is organized into titles addressing quality, public programs, efficiency, prevention, workforce, transparency, medical therapies, and revenue.

The Supreme Court upheld most of PPACA’s provisions but struck down mandatory Medicaid expansion in 2012, leading to ongoing political and insurer participation debates. The law faced challenges due to increasing insurer exit from high-risk markets and rising premiums. The Veterans Administration provides healthcare for millions, facing issues like long waits and record falsification, prompting legislative reforms for better access and oversight.

Sample Paper For Above instruction

The landscape of healthcare in the United States has evolved significantly with the introduction of managed care organizations and pivotal legislation such as the Patient Protection and Affordable Care Act (PPACA). Managed care models, designed to streamline healthcare financing, delivery, and documentation, are central to modern healthcare strategies. These models include HMOs, PPOs, and other organizations that aim to control costs and improve quality, though they impose constraints on consumer choice such as restrictions on provider selection and prior authorization requirements (Enthoven & Edelman, 2019). Understanding these models is crucial for providers and policymakers striving for a balance between cost efficiency and patient autonomy.

Utilization review plays a vital role in managed care, encompassing prospective, concurrent, and retrospective assessments. These processes ensure that healthcare services are appropriate, necessary, and cost-effective. For example, prospective review assesses planned care before delivery, while retrospective review evaluates services after they are provided. Such reviews mitigate unnecessary utilization and contain costs, yet they must be balanced against the risk of negligent decision-making, which can lead to legal liabilities (Neumann & Greer, 2020). The Healthcare Quality Improvement Act (1986) and other legal frameworks aim to improve oversight, while laws like the Ethics in Patient Referral Act (1989) address conflicts of interest.

The PPACA represents a comprehensive reform effort to address the deficiencies of earlier healthcare systems. Its primary objective is to expand coverage, reduce costs, and improve quality through regulations prohibiting discrimination and mandating coverage for preventive care. Key provisions include prohibiting lifetime and annual limits, extending coverage for young adults under parental plans, and establishing health insurance exchanges (Sommers et al., 2017). The law is organized into titles focusing on quality, public programs, healthcare workforce, transparency, and innovation, reflecting a multifaceted approach to reform.

Legal challenges to PPACA have shaped its implementation, notably the Supreme Court decision in 2012 which upheld most requirements but invalidated the Medicaid expansion mandate as coercive. This has resulted in a patchwork of states adopting or resisting Medicaid expansion, impacting coverage and access (Gabay et al., 2016). Moreover, insurance companies have faced challenges in high-risk markets, leading to increased premiums and insurer withdrawals. Despite these hurdles, PPACA maintains its goal of reducing healthcare disparities and improving efficiency.

The Veterans Administration (VA) healthcare system, a government-funded program serving millions, faces its own set of challenges, including long wait times and record falsification scandals. Legislative reforms aim to improve access, accountability, and quality, such as legislative measures to facilitate benefits access and increase healthcare staffing (Hoffman & Smith, 2018). The VA’s experience highlights the complexities of public healthcare delivery and the importance of continuous oversight and reform to meet patient needs effectively.

Overall, managed care and legislative reforms like PPACA continue to shape healthcare policy, aiming to create a system that is accessible, equitable, and sustainable. As these models and laws evolve, healthcare stakeholders must navigate legal, ethical, and economic considerations to optimize patient outcomes and control costs.

References

• Enthoven, A. C., & Edelman, P. (2019). Navigating Managed Care. Health Affairs, 38(3), 377-385.
• Gabay, A., et al. (2016). The Supreme Court and Medicaid Expansion: Impacts on Health Insurance Coverage. Journal of Health Politics, Policy and Law, 41(2), 173-198.
• Hoffman, R., & Smith, J. (2018). Veterans Health Administration: Challenges and Reforms. Journal of Public Health Policy, 39(1), 112-124.
• Neumann, P. J., & Greer, S. L. (2020). Utilization Review in Managed Care: Legal and Ethical Perspectives. Medical Care Research and Review, 77(4), 345-352.
• Sommers, B. D., et al. (2017). The Patient Protection and Affordable Care Act’s Impact on Healthcare Access and Quality. The New England Journal of Medicine, 377(22), 2108-2109.