Wait a second!
More handpicked essays just for you.
More handpicked essays just for you.
Cost control in managed care
Don’t take our word for it - see why 10 million students trust us with their essay needs.
Recommended: Cost control in managed care
Managed care, as it relates to providers healthcare, can be defined as a patient that only sees the doctors and specialists that are in their health plan. In compliance to this agreement, the co pays are lowered by a managing company who oversees all health care interactions of their clients. The reason these costs are kept significantly lowers is because the company has contracts with particular healthcare providers and hospitals. There are three different types of managed care plans that are available. These are Heal Maintenance Organizations (HMO), Preferred Provider Organizations (PPO), and Point of Service plans (POS). Each is a little different from the other, but provide the same basic service, managed health care. The main goal of
Membership Services (MSD) at Kaiser Permanente used to be a modest department of sixty staff. However, over the past few years the department has doubled in size, creating minor departmental reorganization. In addition the increase of departmental staffing, several challenges became apparent. The changes included primary job function, as well as the introduction of new network system software which slowed down the processes of other departments. These departments included Claims (who pay the bills for service providers outside of the Kaiser Permanente network), and Patient Business Services (who send invoices to members for services received within Kaiser Permanente). Due to the unforeseen challenges created by the system upgrade, it was decided that MSD would process the calls for both of the affected departments. Unfortunately, this created a catastrophic event of MSD receiving numerous phone calls from upset members—who had received bills a year after the service had been provided. The average Monday call volume had risen from 1,800 to 2,600 calls per day. The average handling time for each phone call had risen as well—from an acceptable standard of 5.6 minutes to an unfavorable 7.2 minutes. The department continued to be kept inundated with these types of calls for the two years that these changes have been effect.
Managed care is one of the leading form health care in the United States. It has become very popular and many people in the United States have taken advantage of it. There are a few different types of managed care programs: Health Maintenance Organizations or HMOs, Preferred Provider Organizations or PPOs, and Point of Service Plans or POSs. Each one of these types of managed care plans has its pros and cons (Cyrene, 2015). If you would ask a few people what types of insurance they have, they are more than likely going to name off a managed care plan because it is more common to find someone with a managed care plan than not. Managed care has changed the healthcare system in many ways, some for the good and
Integrated Managed Care Organization- The organization is properly aligned for the primary driver being cost cutting services. Since all entities within the organization are responsible and affected by any expenses endured on any entity being unfavorable or favorable, the foundation serves as a primary motivator to reduce costs at all levels. This alignment eliminates any financial gains from driving high utilization of services or higher intensity services within the organization. Ultimately, this system allows the physician medical group to drive patient care, being responsible for the clinical care decisions as opposed to health plan making those decisions as designed in other organizations. This is the preferable model for Medicaid
Health Maintenance Organization (HMO) is a group of individual health plans that are intended to provide services for costumers’ that purchase insurance policies and for those that cannot afford health insurance. Many of these organization are led by physicians, and other professionals that network together to make health care affordable for patients. In the HMO category there are five separate managed care plan models. First, the Group Model (HMO), is a group that has a number of physicians that mainly agree to provide care to a defined group of patients in return for a fix rate capita payment for discounted fees from insurance companies (Henderson, 2012 p.212).
When one examines managed health care and the hospitals that provide the care, a degree of variation is found in the treatment and care of their patients. This variation can be between hospitals or even between physicians within a health care network. For managed care companies the variation may be beneficial. This may provide them with opportunities to save money when it comes to paying for their policy holder’s care, however this large variation may also be detrimental to the insurance company. This would fall into the category of management of utilization, if hospitals and managed care organizations can control treatment utilization, they can control premium costs for both themselves and their customers (Rodwin 1996). If health care organizations can implement prevention as a way to warrant good health with their consumers, insurance companies can also illuminate unnecessary health care. These are just a few examples of how the health care industry can help benefit their patients, but that does not mean every issue involving physician over utilization or quality of care is erased because there is a management mechanism set in place.
Health Maintenance Organizations, or HMO’s, are a very important part of the American health care system. Also referred to as managed care programs, HMO's are combinations of doctors and insurance companies that are formed into one organization. This organization provides treatment to its members at fixed costs and decides on what treatment, if any, will be given based on the patient's or doctor's current health plan. Sometimes, no treatment is given at all. HMO's main concerns are to control costs and supposedly provide the best possible treatment to their patients. But it seems to the naked eye that instead their main goal is to get more people enrolled so that they can maintain or raise current premiums paid by consumers using their service. For HMO's, profit comes first- not patients' lives.
A managed care organization is a collection of clinics, doctors, hospitals, pharmacies and other healthcare providers who come together to offer health care to persons who are sign up for the services. In many cases, managed care organizations operate and are referred to as networks of health care providers. Managed care organizations are comprised of health care experts from different fields who come under an agreement to offer health care services to members. Once a member signs up, all their heath care needs are covered by the managed care organizations. Access to care outside the organization is restricted. Members under managed care organizations are usually assigned a primary care physician (PCP) who is the primary care giver for the member. The PCP is tasked with analyzing a member’s health problem before referring them to other sections of the managed care organization. Managed Care Organizations are usually well coordinated to meet the needs of members who have registered under their banner.
Managed care dominates health care in the United States. It is any health care delivery system that combines the functions of health insurance and the actual delivery of care, where costs and utilization of services are controlled by methods such as gatekeeping, case management, and utilization review. Different types of managed care plans came into development by three major factors. These factors include choice of providers, different ways of arranging the delivery of services, and payment and risk sharing. Types of managed care organizations include Health Maintenance Organizations (HMOs) which consist of five common models that differ according to how the HMO is related to the participating physicians, Preferred Provider Organizations (PPOs), Exclusive Provider Organizations (EPO), and Point of Service Plans (POS). `The information management system in a managed care organization is determined by the structure of the organization' (Peden,1998, p.90). The goal of a managed care system is to provide subscribers and dependants with needed health care services at the lowest possible cost. Certain managed care plans also focus on prevention by trying to keep members healthy.
Tricare previously known as the Civilian Health and Medical Program of the Uniformed Services (CHAMPUS) is a health care program of the United States Department of Defense Military Health System (tricare.mil). Tricare gives non-military personnel medical advantages to military work force, military retirees, and their wards, including a few individuals from the Reserve Component. Tricare is the regular citizen care segment of the Military Health System, although verifiably it additionally included medicinal services conveyed in the military therapeutic treatment offices. Tricare, the military's medical coverage plan, covers everybody; including active-duty members, retirees, and their families. Be that as it may, retirees and their dependents
Americans these days need an affordable universal health insurance from the American government , Can the government give what the people need ? First of all many americans owe the government cause they can’t afford their medications , Second of all is Obama care really is worth it ? , Furthermore the US’s medical System is not working for most of the people who is on medication. US spends far and away more on healthcare than any other. Half of the americans are uninsured by the government. Over Half of the american population hasn’t gotten their Insurance and even if they do they still pay a lot of money for their medication.
Blue Cross and Blue Shield (BCBS) headquarters are located in chicago, illinois. It was founded in 1929. It has a federation of 36 separate united states health insurance organizations providing healthcare to more than 106 million americans.
What is managed care? According to the Oxford English Dictionary, managed care is “a system of health care in which patients agree to visit only certain doctors and hospitals, and in which the cost of treatment is monitored by a managing company.” Managed care is a variety of techniques designed to reduce the cost of providing health benefits and advance the quality of care. In the United States alone, there are various managed care programs, that are ranged from more restrictive to less restrictive. As stated in the National Institutes of Health, the future of managed care is uncertain.
Managed care is simply a system that delivers health care to a specific population purchased through health insurance plans. Practitioners and providers manage the use of health care services and cost by providing effective diagnosis and treatment, appropriate use of inpatient and outpatients facilities, population-based planning, health promotion and education, and disease prevention. Managed care uses a “gatekeeper” system, where patients or beneficiaries are assigned a Primary Care Physician (PCP), who they see initially for all medical care. The PCP acts as a gatekeeper by initiating referrals to specialists when required and approving inpatient admissions. Managed care was seen across communities in America as early as the 19th century and by 1938, Henry Kaiser had adopted a pre-paid medical plan for his employees. During World War II Kaiser used pre-paid medical programs for his workers and after the war he opened these plans to the public, which became the Kaiser Permanente we know today. Pre-paid healthcare and Health Maintenance Organizations (HMOs) came into full use in the 1970’s when the federal government established grants and loans as part of a health care strategy to provide care for uninsured Americans by increasing the number of HMO, increasing enrollment, and containing the cost of healthcare. Since the 70’s employers have used managed care as a form of high quality low cost insurance for their employees and the federal government has turned to managed care for both Medicare and Medicaid programs.
March 10, 2016 Medical Care Organization Case Analysis Reason for the Case: The reason fort the case is to provide guidance to DR. Rodriguez how to efficaciously implement an electronic medical record system into her medical practice within short period of time and show her in what way she can benefit financially. Summary of the Case:
Managed health care actually combines health care delivery with the financing of services provided. This was intended to replace conventional fee-for service plans with much more affordable quality of care to the health consumers as well as the providers who was in agreement with the restrictions. However, managed care is becoming challenged due to the growth of consumer-directed health plans, which defines employer continuations and asking employees to be more responsible within their health care decisions and cost-sharing. The Americans health care system has been changing the way their health care services are organized and delivered. As seen by the movement from traditional fee-for-service systems to managed care networks. Ranging from structured staff model HMOs to the lesser structured preferred provider organizations (PPO). Statistics show that 60 million Americans are enrolled with some type of managed care program within the response to regulatory initiatives which affect health care cost and quality. Managed care organizations are responsible for the health of their enrollees, which can be administered by a physician’s group, health system, or even a hospital. Much of the managed care financing is through a method called capitation, and the enrollees are assigned to a select primary care provider, which serves as a gatekeeper.