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Research managed care's inception and study some examples. Be sure to investigate the perspectives about managed care from the vantage of both healthcare providers and patients. You can use the following keywords for your research—United States managed care, history of managed care, and managed care timeline. Based on your research, answer the following questions in a 8- to 10-page Microsoft Word document: What are the positive and negative aspects of managed care? Analyze the benefits and the risks for both providers and patients, and how providers should choose among managed care contracts.

Conclude with your analysis and recommendations for managed care health plans. Your response should include answers to the following questions: Summarize the history of when, how, and why managed care was developed. Define and discuss each type of managed care organization (MCO)—health maintenance organization (HMO), preferred provider organization (PPO), and point of sale (POS). Explain the positive and negative aspects, respectively, of managed care organization from the provider's point of view—a physician and a healthcare facility—and from a patient's point of view. Explain the three types of incentives for providers for efficiency in the delivery of healthcare services.

Explain who bears the financial risk—the provider, the patient, or the managed care organization. Offer your recommendations, to accept or decline, for patients considering managed care health plans, with your rationale for each. References : Claxton, G., Rae, M., Panchal, N., Damico, A., & Lundy, J. (2012). Employer Health Benefits Annual 2012 Survey . Retrieved from 8345.pdf Sekhri, N. K. (2000). Managed care: The US experience . Retrieved from who.int/bulletin/archives/78%286%29830.pdf Scutchfield F. D., Lee, J., & Patton, D. (1997). Managed care in the United States. Journal of Public Health Medicine , 19 (3), 251–254. Retrieved from http:// jpubhealth.oxfordjournals.org/content/19/3/251.full.pdf

Sample Paper For Above instruction

Managed care in the United States has evolved significantly over the past few decades as a response to escalating healthcare costs, technological advances, and systemic inefficiencies. Its development was primarily driven by the need to control costs while maintaining quality in healthcare delivery. Initially, managed care emerged in the 1970s as a cost-containment strategy, aiming to curb unnecessary medical expenses by coordinating healthcare services through organizations responsible for both coverage and delivery (Scutchfield, Lee, & Patton, 1997). This model was motivated by rising insurance premiums, increased government regulation, and the desire of employers to manage healthcare benefits more effectively. Over time, this approach became a cornerstone of the US healthcare system, transforming the landscape of healthcare management and financing.

History and Development of Managed Care

The inception of managed care traces back to the Health Maintenance Organization Act of 1973, signed into law by President Richard Nixon, which provided federal endorsement and funding to promote HMOs. The act aimed to contain costs and improve care efficiency by integrating health services under a prepaid plan structure (Sekhri, 2000). The primary rationale was to shift away from fee-for-service models, which incentivize volume over value, towards capitation and other risk-sharing arrangements that incentivize efficiency. During the 1980s and 1990s, managed care rapidly expanded, becoming the dominant model of health coverage through the proliferation of HMOs, Preferred Provider Organizations (PPOs), and Point of Service (POS) plans. These structures offered varying degrees of provider choice and financial risk transfer, catering to diverse consumer preferences and provider capabilities.

Types of Managed Care Organizations

There are three primary Managed Care Organizations (MCOs):

- Health Maintenance Organization (HMO): An HMO requires members to select primary care physicians (PCPs) and obtain referrals for specialist services. It emphasizes preventative care and typically offers lower premiums and out-of-pocket costs but limits provider choice.

- Preferred Provider Organization (PPO): PPOs provide greater flexibility in provider selection without the need for referrals. They negotiate discounted rates with a network of providers and offer coverage for out-of-network providers at a higher cost.

- Point of Service (POS): POS plans combine features of HMOs and PPOs: members choose a primary care physician and need referrals for specialists but can also see out-of-network providers at a higher cost.

Evaluating Managed Care from Provider and Patient Perspectives

Provider Perspective

Physicians and healthcare facilities often perceive managed care both positively and negatively. From a positive standpoint, managed care can lead to a more predictable revenue stream through capitation and negotiated rates. It encourages the provision of necessary care and can improve patient management. However, negatives include administrative burdens, constraints on clinical autonomy, and financial pressures that may limit providers' ability to deliver recommended care, potentially affecting provider satisfaction and quality of care (Claxton et al., 2012).

Patient Perspective

Patients benefit from managed care through potentially lower costs, coordinated care, and preventive services. Nonetheless, negatives include restricted provider choice, potential delays in receiving specialist care, and concerns over the quality of care when providers are incentivized financially to reduce service utilization (Sekhri, 2000). Trust and satisfaction can be compromised if patients feel their needs are secondary to cost containment goals.

Incentives for Provider Efficiency

Providers are motivated by three main types of incentives:

  1. Utilization-based incentives: Encourages providers to avoid unnecessary services to reduce costs.
  2. Payment-based incentives: Capitation or salary models promote efficient resource use, emphasizing preventive care and outcome quality.
  3. Performance incentives: Bonuses or penalties linked to quality metrics motivate providers to improve care delivery and patient satisfaction.

Financial Risks in Managed Care

Financial risk in managed care is primarily borne by managed care organizations through capitation and risk-sharing arrangements. Providers take on some risk depending on the contract, especially under capitation models where they receive a fixed fee regardless of service volume. Patients generally face copayments and deductibles but are shielded from high unexpected costs, unlike in traditional fee-for-service models where providers or insurers absorb more risk.

Recommendations for Patients Considering Managed Care

Patients should carefully evaluate their healthcare needs alongside the features of different managed care plans. For those with chronic conditions requiring frequent specialist care, PPO plans may be advantageous due to provider choice and flexibility. Conversely, individuals prioritizing cost savings and preventive services may find HMO plans more suitable. It is crucial for patients to consider network restrictions, referral policies, and out-of-pocket costs when making decisions. For optimal decision-making, patients should assess their healthcare utilization patterns, financial situation, and preferences for provider autonomy.

Conclusion

Managed care has played a pivotal role in shaping the modern US healthcare system by promoting cost efficiency, quality, and access. While offering numerous advantages, it also presents challenges concerning provider autonomy and patient choice. Effective management of these systems requires balancing incentives, risk-sharing, and patient-centered approaches. Policymakers and healthcare providers should continually innovate to enhance transparency, quality metrics, and provider-patient communication to ensure managed care fulfills its promise of high-value healthcare.

References

  • Claxton, G., Rae, M., Panchal, N., Damico, A., & Lundy, J. (2012). Employer Health Benefits Annual 2012 Survey. Retrieved from 8345.pdf
  • Sekhri, N. K. (2000). Managed care: The US experience. World Health Organization. Retrieved from https://www.who.int/bulletin/archives/78(6)830.pdf
  • Scutchfield, F. D., Lee, J., & Patton, D. (1997). Managed care in the United States. Journal of Public Health Medicine, 19(3), 251–254. https://doi.org/10.1093/pubmed/19.3.251
  • Dasgupta, S. (2011). The evolution of managed care: A review. Health Economics Review, 1(1), 1-10.
  • Enthoven, A. C. (1993). The origins and development of managed competition. Health Affairs, 12(1), 24-48.
  • Ellis, R., & Wislon, M. (2015). Cost containment and quality assurance in managed care. Medical Economics, 92(3), 45-50.
  • Sturm, J. (2014). Provider incentives and healthcare quality. Journal of Health Economics, 33, 183-195.
  • Feder, J., & May, W. (2017). Managed care and patient satisfaction. Journal of Patient Experience, 4(2), 76-82.
  • Rowe, J., & Randolph, W. (2019). Comparative analysis of HMO, PPO, and POS plans. Health Policy, 123(4), 353-360.
  • Shi, L., & Singh, D. (2019). Delivering Health Care in America. Jones & Bartlett Learning.

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