Research A Managed Care Organization (MCO) Online And Discus ✓ Solved

Research a Managed Care Organization (MCO) online and discus

Research a Managed Care Organization (MCO) online and discuss the similarities and differences among six medical management committees within that MCO. For each committee, analyze its main role. Identify which of the six committees you consider least important, and justify your choice with specific examples from your research. Compare how the information you found online aligns with or differs from the assigned readings. Then examine how public policy has impacted the growth of managed care: evaluate the impact of one federal policy and one state-level policy, and compare and contrast how each policy caused the managed care market to grow or retract. Cite sources in APA format and provide references.

Paper For Above Instructions

Introduction

Managed care organizations (MCOs) use formal committee structures to govern clinical policy, quality, utilization, pharmacy decisions, credentialing, and member appeals. Using Blue Cross Blue Shield (BCBS) and comparator MCO documentation (Aetna, CMS guidance, NCQA and URAC standards), this paper describes six common medical management committees, compares similarities and differences, evaluates the principal role of each, identifies the committee judged least important for day-to-day operations, and analyzes how public policy at federal and state levels has shaped the managed care market (Kongstvedt, 2013; Blue Cross Blue Shield Association, n.d.; Aetna, n.d.).

Six Common Medical Management Committees

1. Medical Advisory (Medical Executive) Committee

   Role: Provides clinical expertise, advises leadership on clinical policy, clinical guideline adoption, and system-level medical strategy. These committees are typically composed of practicing physicians and specialists who review clinical practice issues and advise the MCO’s board/executive management (Kongstvedt, 2013).

2. Utilization Management (UM) Committee

   Role: Sets and monitors utilization review criteria, prior authorization policies, and appeals procedures for service authorization. UM committees operationalize access controls and manage cost/quality tradeoffs in care delivery (NCQA, n.d.; URAC, n.d.).

3. Quality Improvement (QI) / Performance Improvement Committee

   Role: Oversees clinical quality programs, performance metrics, patient safety initiatives, and continuous improvement activities required for accreditation (NCQA, n.d.). This committee prioritizes measures (HEDIS, CAHPS) and monitors remediation plans.

4. Pharmacy & Therapeutics (P&T) Committee

   Role: Reviews clinical evidence, develops formulary policies, evaluates new medications, and recommends utilization controls for pharmaceuticals (Aetna, n.d.). P&T committees directly affect patient access to medications and cost management.

5. Credentialing and Peer Review Committee

   Role: Establishes credentialing standards, evaluates provider qualifications, performs privileging or network participation reviews, and conducts peer review of clinical competence (BCBS Association, n.d.).

6. Appeals, Grievance and Member Services Committee

   Role: Reviews member complaints and grievances, manages appeals processes, and ensures regulatory compliance with consumer protection rules. This committee interfaces closely with compliance/legal functions (NCQA; URAC).

Similarities and Differences Across an MCO (BCBS example)

Similarities: Across BCBS plans and other national MCOs (Aetna, Humana), the committees listed above exist in some form because accreditation standards (NCQA, URAC) and regulatory frameworks require oversight of utilization, quality, pharmacy, credentialing, and member grievance processes. Each committee usually includes clinical and administrative representation and uses evidence-based guidance to shape policy (NCQA, n.d.; URAC, n.d.).

Differences: Differences arise in committee authority and frequency. For example, the BCBS Association often delegates operational implementation to regional plan management while the Medical Advisory Committee remains advisory (Blue Cross Blue Shield Association, n.d.). Some MCOs centralize P&T decisions nationally (for purchasing leverage), while others let regional plans set formularies. Credentialing processes can be more centralized in larger insurers with proprietary vendor support, whereas smaller plans may rely on local medical staff for peer review (Aetna, n.d.; BCBS Association, n.d.).

Main Role Analysis

The most operationally consequential committees are UM, P&T, and QI because they directly influence access, clinical pathways, and measurable outcomes (Kongstvedt, 2013; NCQA, n.d.). UM impacts authorization and thereby patient access and cost control. P&T affects medication access, adherence, and pharmacy spend. QI drives metrics that determine contract performance and accreditation. Credentialing affects network composition and clinical safety, and Appeals/Grievance protects member rights and regulatory compliance. The Medical Advisory Committee, while important for clinician engagement, typically exercises advisory influence rather than direct operational control (Blue Cross Blue Shield Association, n.d.).

Least Important Committee—Argument and Justification

When prioritizing committees by immediate operational impact on access, cost, and measurable quality outcomes, the Medical Advisory Committee is often the least operationally critical. It plays a vital consultative role but rarely controls day-to-day decisions such as prior authorization criteria (UM), formulary edits (P&T), or remediation of quality shortfalls (QI). For example, BCBS plan documentation shows Medical Advisory bodies making clinical recommendations that are implemented by UM and P&T operational teams (Blue Cross Blue Shield Association, n.d.). In contrast, a change in UM criteria can immediately alter utilization patterns and expenditures (NCQA, n.d.). Therefore, while the Medical Advisory Committee is essential for clinician buy-in and legitimacy, its role is more strategic-advisory and less directly enforcement-oriented than UM or P&T.

Online Findings vs. Assigned Readings

Online sources (insurer websites, NCQA, URAC) emphasize functional descriptions, accreditation requirements, and operational procedures for committees. Textbook readings (Kongstvedt, 2013) add historical context, conceptual frameworks (managed competition, cost-control mechanisms), and the rationale behind committee structures. Thus online sources are more prescriptive and current, while academic readings provide theory and evolution—complementary perspectives rather than contradictions.

Public Policy Impact: Federal and State Examples

Federal policy—HMO Act of 1973: The HMO Act provided federal endorsement, grants, and removed regulatory barriers to HMO development, enabling rapid growth of organized delivery systems and managed care enrollment (Pub. L. No. 93-222, 1973). It encouraged employer adoption and federal contracting, accelerating market expansion (Congress.gov, 1973).

State policy—California Knox-Keene Health Care Service Plan Act: Knox-Keene created a regulatory framework requiring licensure, financial solvency, consumer protections, timely grievance procedures, and reporting for health plans. While increasing compliance costs for plans, it also increased consumer trust in managed care products, supporting enrollment growth in California but sometimes deterring smaller entrants due to regulatory burden (California Department of Managed Health Care, n.d.).

Comparison: The HMO Act stimulated supply-side growth by facilitating entry and federal support; it reduced barriers and created incentives for employers and federal purchasers. State-level regulation like Knox-Keene often constrained uncontrolled expansion via consumer protection requirements, thereby imposing higher operating costs but improving market stability and public confidence. Both forces shaped the market: federal policy fostered expansion, while state regulation channeled growth toward more regulated, accountable plan types (Kongstvedt, 2013; DMHC, n.d.).

Conclusion

MCO committee structures align around functions that govern access, quality, pharmaceutical management, provider competence, and member protections. While all six committees are important, operational impact varies—UM, P&T, and QI have the most immediate effect on access, cost, and measurable performance. Historical federal policies like the HMO Act accelerated managed care growth, while state laws such as Knox-Keene shaped the market by imposing consumer protections and regulatory standards that altered the form and pace of that growth.

References

• Kongstvedt, P. R. (2013). Managed Care: What It Is and How It Works (5th ed.). Jones & Bartlett Learning.
• Blue Cross Blue Shield Association. (n.d.). About us. https://www.bcbs.com
• Aetna. (n.d.). Medical management. https://www.aetna.com
• National Committee for Quality Assurance (NCQA). (n.d.). Quality improvement. https://www.ncqa.org
• URAC. (n.d.). Utilization management accreditation standards. https://www.urac.org
• Kaiser Family Foundation. (2020). Medicaid managed care. https://www.kff.org/medicaid/issue-brief/medicaid-managed-care/
• Congress.gov. (1973). HMO Act of 1973, Pub. L. No. 93-222. https://www.congress.gov/bill/93rd-congress/house-bill/5384
• California Department of Managed Health Care. (n.d.). Knox-Keene Health Care Service Plan Act. https://www.dmhc.ca.gov
• Centers for Medicare & Medicaid Services. (n.d.). Medicare Advantage (Part C). https://www.cms.gov/medicare/health-plans/medicareadvtg
• Blue Cross Blue Shield Association. (n.d.). Medical management and quality programs. https://www.bcbs.com/what-blue-cross-blue-shield