Managed Care In The United States: Managed Care Is Becoming

Managed Carein The United States Managed Care Is Becoming An Increasi

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 an 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. Support your responses with examples. Cite any sources in APA format.

Paper For Above instruction

Managed care is a pivotal component of the United States healthcare system, developed in response to rising healthcare costs and the need to improve efficiency and quality of care. Its history dates back to the mid-20th century, with roots in prepaid health plans established during the 1930s and 1940s. The development of managed care was influenced by the escalating costs associated with fee-for-service (FFS) models, which often lacked cost containment and led to inefficient resource utilization. Managed care emerged as a strategic response by insurance companies, healthcare providers, and policymakers to control costs while maintaining quality, ultimately shaping the structure of modern healthcare delivery in the U.S. (Scutchfield, Lee, & Patton, 1997).

There are three main types of managed care organizations (MCOs): Health Maintenance Organizations (HMOs), Preferred Provider Organizations (PPOs), and Point of Service (POS) plans. HMOs are characterized by comprehensive coverage provided through a network of providers, emphasizing preventive care and requiring members to select primary care physicians (PCPs) who coordinate all healthcare services. PPOs offer greater flexibility in choosing providers and do not require referrals, usually featuring a network of preferred providers with whom negotiated rates are established, but also allowing out-of-network services at higher costs. POS plans combine elements of HMOs and PPOs, giving enrollees the option to see out-of-network providers but often at increased cost and with the need for referrals from PCPs (Enthoven & Van de Ven, 2007).

From the provider's perspective, managed care presents both benefits and challenges. Positively, MCOs can ensure a steady patient volume, streamline administrative processes, and potentially increase revenue streams through capitated payments. Conversely, providers often face restrictions on autonomy, limited reimbursement rates, and pressures to adhere to utilization controls, which may impact clinical decision-making negatively. Healthcare facilities may also benefit from contracts that guarantee patient inflow but struggle with administrative burdens and reduced reimbursement margins, especially when negotiating with various MCOs (Rosenblatt & Shenson, 2012).

For patients, managed care can offer cost savings, improved access to preventive services, and coordinated care. However, negative aspects include limited provider choice, potential restrictions on specialist access, and the possibility of reduced care quality if providers prioritize cost containment over personalized treatment. Patients often have to navigate complex networks and authorization processes, which can delay care or restrict access to desired services (Claxton et al., 2012).

Regarding incentives for providers to deliver efficient care, three main types are prevalent: financial incentives tied to capitation, salary, or productivity-based pay, as well as bonuses for meeting quality metrics. Capitation provides a fixed payment per patient regardless of actual services delivered, incentivizing cost-efficient care but risking underservice. Salary-based incentives promote stability but may diminish motivation for efficiency. Productivity-based incentives encourage providers to see more patients but can compromise quality if quantity is prioritized. Quality improvement incentives, such as bonuses for meeting patient satisfaction and health outcomes, aim to balance cost and quality (Sekhri, 2000).

The financial risk in managed care is predominantly borne by the managed care organizations themselves, especially within capitation and global budgets, which require MCOs to pay providers a fixed rate regardless of actual costs. Patients typically have co-payments or coinsurance but do not directly bear significant financial risk. Providers assume some risk when contractually responsible for cost containment and quality targets, but the overall system shifts risk away from individual practitioners towards organizations (Rosenblatt & Shenson, 2012).

For patients considering enrolling in managed care plans, a careful evaluation of their healthcare needs, provider networks, and plan specifics is essential. Those seeking comprehensive, cost-effective primary care and willing to accept network restrictions may find HMOs advantageous. Patients desiring greater flexibility and out-of-network options might prefer PPOs despite higher costs. POS plans are suitable for individuals valuing flexibility but willing to navigate referral processes. My recommendation is that consumers assess their healthcare utilization patterns, financial capacity, and preferences for provider choice before selecting a plan. For those with chronic conditions or frequent healthcare needs, plans emphasizing coordinated, comprehensive care tend to be more beneficial. Conversely, healthy individuals with limited provider preferences may prefer less restrictive plans, balancing cost and access according to their unique needs (Claxton et al., 2012).

References

• Claxton, G., Rae, M., Panchal, N., Damico, A., & Lundy, J. (2012). Employer Health Benefits Annual 2012 Survey.
• Enthoven, A. C., & Van de Ven, W. P. (2007). A segmentation theory of healthcare markets. Health Affairs, 26(6), 1573-1681.
• Rosenblatt, R. A., & Shenson, D. (2012). Managed Care and Healthcare Quality. Journal of Health Economics, 31(2), 330-341.
• Sekhri, N. K. (2000). Managed care: The US experience. Bulletin of the World Health Organization, 78(6), 830-836.
• Scutchfield, F. D., Lee, J., & Patton, D. (1997). Managed care in the United States. Journal of Public Health Medicine, 19(3), 251–254.