Components Related to Managed Care
Introduction
Managed care refers to deploying initiatives that integrate healthcare providers with the pertinent issues that directly influence cost and quality of care. The United States has been at the forefront of promoting these concepts through a support system for a competitive health insurance system. The policy structures have flexed and accommodated the emergence of new companies that offer different sets of insurance policies. As a result, the healthcare system has shifted from traditional approaches of principled-based settings to value-based care. Many healthcare facilities in the United States are integral to indemnity insurance, employer-base, and conditioned to fee-for-service healthcare. As a result, the government has taken the initiative of redeveloping the Medicaid and Medicare services through the establishment of the Affordable Care Act (ACA) of 2010. This approach aims to enhance access to healthcare services irrespective of individual socioeconomic status or level of disease susceptibility or burden. This paper provides comparisons and contrasts related to managed care organization, Medicare, and Medicaid.
The Concerns of “Gatekeeping” in Managed Care Organization
Gatekeeping has been identified as one of the first evolution in the United States concerning managed care. Physicians are now considered as the bridge to specialty care and other medical resources. There has been a proliferation of this model by the government through a sponsored program that supports referrals basis for primary care. As a result, gatekeeping has been linked with unethical considerations of uneven distribution of resources, population segregation due to socioeconomic factors, and financial difficulties to the patients. The use of this model prohibits the patient from being much engaged in the process of decision making, which primarily violates the patient autonomy factor. In this context, the physician is responsible for the patient’s treatment and in charge of authorizing hospitalization, referrals, and lab tests. In instances where the patient suffers from particular health disparities, the specific “gatekeeper” provides a guideline for the case management through the use of a healthcare plan network comprising the specialization and resources required to address the concerns.
This approach has been considered as cost-friendly in terms of preventing unnecessary medical care interventions compared to secondary care services, whereby the patient has to go through numerous consultations with various providers to substantiate the ultimate diagnosis and treatment. These primary care physicians are more skilled and knowledgeable in seeking specialist care for the patients than personal initiative. Qualitative studies have been conducted and discovered that this model of care alters physicians’ perceptions, whereby they feel as if their roles have been diminished to health insurance administrators. This aspect has influenced the capitalist approach in treatment directives and led to the introduction of financial consideration to treatment decisions. To some level, this module has structured the unequal nature of patient access to quality and satisfactory healthcare services.
The managed care organizations have continued to emphasize the physicians’ responsibility to regulate access to specialty care, and expensive hospitalization thus contributed to the ultimate cost factors. Reducing the inappropriate use of specialty services has enhanced population health by reducing medical errors and unnecessary hospital spending. The differential perceptions from many Americans concerning gatekeeping have been connected with the limited or unlimited use of ambulatory care services. However, this concept has played critical roles in balancing healthcare organizations’ primary tools in the United States. One significant implication is the uncertainty of the initiative containing health expenditure since there are numerous factors to consider: health-related quality of life, health outcomes, utilization of healthcare services, and quality of care.
The Perceptions of Medicare
The government initiated the Medicare program through the ACA of 2010. Its primary purpose was fulfilling the federal initiatives of managed care through promoting access to medical services for the elderly during their end of life. There are over 60 million beneficiaries to these services, which stipulate applicants that are over 65-years-old and younger populations with disabilities. Based on the study conducted in 2016, 14 percent of household spending accounted for the Medicare health expenses, which was twice the non-Medicare household. Therefore, there has been an increase in the financial burden on employer-sponsored insurance, which has influenced the reduced provision of supplemental coverage by the employers to their retired employees. The primary goal of every health insurance cover is to protect individuals from unanticipated healthcare expenditure. Approximately, over 50 percent of health complications are experienced above the age of 65-years-old, thus increasing the mandates advance care planning. Medicare has facilitated the aspect of distributing medical expenditure and balancing the out-of-pocket spending for Americans in general. Ideally, the program has decreased the exposure to medical expenditure risks and increased the number of insured Americans. Medicare covers approximately 65 percent of the healthcare costs, out-of-pockets accounts for 12 percent. At the same time, the rest is dependent on other plans of cost coverage that the patient might be registered with, including private insurances. The policymakers have begun to scale down to realistic financial capabilities related to Medicare services, which have influenced the employers to cut down the retiree health benefits contributions.
Alternatives for Ease the Drain on Medicare Resources
One of the ways to ease the drain on the Medicare resources is to improve the health of retirees and beneficiaries by promoting preventive care such as health education, dietary guidance, and enhancement of ambulatory care services. The reduced number of hospital visits would minimize the Medicare expenditure for the aged population. Increased health knowledge would foster effective personal management of health conditions and observation of healthy lifestyles by the patients. Improving their health status would also encompass the strengthening of public health initiatives, which cover the concepts of population assessment, assurance, and empowerment in promoting well-being and safety.
The next alternative involves improving the healthcare delivery system’s efficiency to prevent occurrences, such as prolonged hospital stays, medical errors, and adverse health complications. Competence among healthcare professionals is one of the critical concerns in this context whereby efforts should be established to enhance efficiency, professionalism, and continual adoption of evidence-based practices and initiatives for care by the healthcare providers. The managed care organizations can incorporate improved incentives options for the providers and, at the same time, set the principle standards of delivering care to propel the physicians and nurses to reduce the disease burden using cost-effective approaches. Quality and safety play critical roles in promoting positive patient outcomes, which, in return, supports the adoption of value-based care. Lastly, there should be an initiative for increasing the income taxes paid on the general national fund to enhance support for part B and D beneficiaries. This approach would fulfill the primary goals of Medicare, which involves promoting universal care. More Americans would be enrolled and will stand to benefit from the program regardless of their financial incapability.
The Relation of Medicaid to Long-Term Care
Medicaid was established to spread access to healthcare services for needy families and societies under limited resources and low-income. It is a jointly funded program by both the state and federal governments but managed mainly by the state governments. To be eligible for the services, he or she must be a legal permanent citizen, including adults with low incomes and their families. The disabled Americans also qualify for enrollment based on their inability to work and earn a living. Examples of services delivered include outpatient hospital services, prenatal care, inpatient hospital stays, and home-care delivery for elderly Americans. Therefore, elderly parents fall under the category of receiving Medicaid services during their long-term care. Currently, the number of users for this program has surpassed the 50-million mark. The program has been discovered to spend more on the elderly population than any other group of recipients. Ultimately, this has led to significant impacts on the state’s budget in funding health insurance policies. It has come out so strongly that millions of older Americans have unlimited sources of income or savings to cover their broad health needs related to the end of life. The long-term care needs have continued to drain the resources for the Medicaid program due to the increasing elderly population with various disease burdens.
Strategies to Ease the Drain on Medicaid Resources
The first module of intervention that would ease the drain on Medicaid resources is to reestablish healthcare policies that would foster the proper utilization of long-term care. The regulatory standards would promote a value-based approach in the delivery of care for the elderly population. Alternatives for this focus should encompass a broader spectrum of multidisciplinary approaches whereby evidence-based practices are utilized to ensure that apart from promoting quality of care, there is also the consideration of cost-friendly model of treatment. Additionally, community resources should act as a supplementary basis for promoting well-being and safety. By partnering with public health educators and programs, different communities can achieve vitality, which is crucial in promoting compliance with the treatment model and integrating cultural affiliations with professional medical directives. As a result, hospital visits would reduce, and patients would be able to take personal responsibility to the management of care.
Instead of paying nursing homes, there should be the promotion of home-based care, which reduces inpatient hospital spending for the seniors. The states and nursing regulatory and management agencies should advocate for adoption of home care whereby limited resources would be used and, at the same time-space would be created within the healthcare centers for other patients. Patients should be enlightened concerning long-term care through training and orientation to prepare to participate in the initiatives. The state government should focus on prospective reimbursement approaches, which create a platform for relating costs and revenue instead of retrospective reimbursement. Through this framework, the state can promote public financing without the risks of overburdening other sectors related to health.
Conclusion
Managed care is a collective concept that requires in inputs of the public, healthcare professionals, and the government to successfully propel healthcare management to quality and value-based concerns. The competitive nature of the healthcare delivery system in the United States has played critical roles in promoting quality and safety in care services. At the same time, it has created a capitalistic approach that has diminished the ethical values of medical principles. However, the Medicaid and Medicare programs have come to level the ground and ensure that everyone accesses care services irrespective of age and socioeconomic status. Nevertheless, the created opportunities for promoting population health have been faced with integrating financial factors with treatment decisions, which has continued to increase the gaps of value, costs, and quality concerns in the United States healthcare system.