Concept of Managed Care and the Health Maintenance Organization
Managed care refers to health insurance, which establishes contracts with particular medical care providers aiming to minimize the cost of health services to patients. Managed care institutions refer to patients as members. The health insurance companies and health care providers such as specialist, hospitals, surgeons, nurse practitioner, and physicians formulate a legal contract or agreement with the provider agreeing to offer listed services at reduced costs. Managed care services comprise of Health maintenance Organization, Preferred Provider Services, and High Deductible Plans. The Health Maintenance Organization managed care service requires patients to use health services within a registered facility, patients get to choose preferred doctors, and low cost but high premiums. Managed care allows patients to receive medical care and health care services at economical prices.
The main economic advantage of medical care programs remains lowering the cost of health care and health care services for people with limited access. Medical care mainly targets people from middle and low-income families in society. Primarily, these groups of people in the community cannot pay for medical care from their low incomes. In addition, medical care programs allow government workers to access affordable health care and health care services, which enables them to serve the population effectively as they spend less and get well quickly. Medical care companies achieve medical care by creating a network of medical providers who can avail care and referrals in case of a health need (Elliott et al., 2011). The increased presence of people within a particular network allows it to provide medical care, medical services, and medical procedures at a discounted price (MCGUIRE et al., 2011). As a result, medical care providers save the community from the high cost of health care and health care services.
Incentives offered by medical care programs mainly reduce the cost of complex chronic diseases such as diabetes. According to Fernandes et al. (2019), diabetes remains the number seven cause of death in the American community. According to the United States National Diabetes statistics, an estimated percentage of 9.4 among the adult population had diabetes as of 2015 (Fernandes et al., 2019). The rate translates to over 23 million diagnosed American (Fernandes et al., 2019). Further, the research by Fernandes et al., (2019), indicates that the majority of the affected people belong to the low-income communities. As a result, offering incentives have encouraged patients to attend medical facilities for medical attention. The incentives applied comprise of monetary and non-monetary applied to consumers, individual providers, or institutions (Abduljawad & Assaf, 2011). According to Fernandes et al., (2019) ‘section 4108 of ACA’ permitted grants spreading for five years that avail grants to states to give incentives to Medicaid members in all age brackets. Availability of incentives encourages individuals to access quality care that allows them to increase performance and productivity in the workplace while investing resources in economic activities rather than spending on health care.
Other alternative forms of payment methods to Health Maintenance Organization includes capitation payments. Capitation payments refer to an arrangement of medical services providers that pay a particular amount for patients assigned to them (Ellis et al., 2017, p. 3). The payment takes place whether the patient seeks or does not seek medical attention. According to James and Poulsen (2016), capitation payments system offers full alignment of the providers’ monetary incentives to eradicate significant waste categories. Besides, the alternative provider payment method lifts the burden managing the form, amount, and care costs from insurers and shifts it to medical practitioners (James and Poulsen, 2016). Providers also receive an adequate amount of money that allows them to offer improved medical care (James and Poulsen, 2016). However, this alternative method of provider payment has some adverse effects on pure health insurers (James and Pouseln, 2016). According to James and Poulsen (2016), capitated payments remove care oversight from Health Management Organizations making them remain as traditional insurance providers tasked with risk analysis, claim processing, marketing, reinsurance, and customer services.
Patients may decide to enrol Health Management Organization or the primary medical care. The original Medicare occurs through the fee-for-service program (Elliott et al., 2011). The two programs differ from each other. Individuals who choose a fee-for-service schedule, has majority enrolments, get enrolled with or without an existing plan for prescription drugs (Elliott et al., 2011). Besides, beneficiaries may enrol in Health management Organization’s Medicare Advantage (MA) plan where they get into contract particular care providers without or with an option for drug prescription. However, these medical care plans possess some differences that influence the quality of health care provided. The fee-for-service members can access providers or physicians of their choice and task with responsibility of self-navigation through the medical care system (Elliott et al., 2011). On the other hand, Medicare Advantage beneficiaries experience different occurrences as determined by the physicians and organizations they opt.
Employers lack entitlement of accessing employees’ information recorded during medical care. The HIPAA restricts employers against accessing employee records and insurance claims as it leads to incidences of discrimination (HHS, 2003, p. 3). Employers who desire to view the medical records and the insurance claims should request written information from the employees. However, workers should provide a doctor’s note at the workplace to request medical leave to access specialized medical care. Doctors lack the permission to release patients’ information to the public (Hibbard et al., 2010, p. 276). Yet, the government, insurance providers, and doctors can access the patient’s information. Indeed, the patients can and should obtain their medical knowledge to aid in evaluating personal health and further steps required with the help of the doctors and other medical care staff.
Conducting the shift from volume-based care to value-based care contains several challenges. The transition process must ensure the protection of data (UIC, 2018). In addition, the transition must also ensure patients’ satisfaction. The common challenge comprises of availing reliable amount of value-based contracts with and active state (UIC, 2018). The transition can persevere past, thus challenge by ensuring the provision of services that lead to patient satisfaction by meeting their expectations. Satisfaction occurs when the transition procedure involves surveys within short periods (UIC, 2018). The studies and doctor’s interactions with patients allow the two to interact at a personal level, which gives the patient the notion of care (Gold et al., 2019, p. 589). In addition, the doctors can quickly learn from past mistakes and seek for rectifications effectively.
Managed care allows patients to access health care and health care services at an affordable price. Patients can choose medical programs from Health Management Organizations or Original medical care. Incentives encourage patients to enrol for medical care services. Employers lack entitlement to access their employees’ medical records, reports, and insurance claims. However, individuals, medical care providers, and the government can access information from patients. Health insurance providers should implement a value-based medical care plan to avail personalized care for the patients.
References
Abduljawad, A., & Assaf, A. F. (2011). Incentives for Better Performance in Health Care. NCBI. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3121024/#:~:text=Incentives%20for%20better%20performance%20in%20health%20care%20have%20several%20modes,consumers%2C%20individual%20providers%20or%20institutions
Elliott, M. N., Haviland, A. M., Orr, N., Hambarsoomian, K., & Cleary, P. D. (2011). How do the experiences of Medicare beneficiary subgroups differ between managed care and original Medicare? Health Services Research, 46(4), 1039-1058. https://doi.org/10.1111/j.1475-6773.2011.01245.x
Ellis, R. P., Martins, B., & Miller, M. M. (2017). Provider payment methods and incentives. International Encyclopedia of Public Health, 133-142. file:///C:/Users/gyf/Downloads/2007_EllisMiller_EncyclopediaPublicHealth_ProviderPayment%20(1).pdf
Fernandes, R., Chinn, C. C., Li, D., Halliday, T., Frankland, T. B., Wang, C. M., Wang, Z., Morioka, M., Arndt, R. G., & Ozaki, R. R. (2019). Financial incentives for Medicaid beneficiaries with diabetes: Lessons learned from HI-PRAISE, an observational study and randomized controlled trial. American Journal of Health Promotion, 32(7), 1498-1501. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6333961/
Gold, S. B., Park, B., Bazemore, A., & Liaw, W. (2019). Response: Re: How evolving United States payment models influence primary care and its impact on the quadruple aim. The Journal of the American Board of Family Medicine, 32(1), 119.1-119. https://doi.org/10.3122/jabfm.2019.01.180293
HHS. (2003). HIPAA Compliance Assistance. https://www.hhs.gov/sites/default/files/privacysummary.pdf
Hibbard, J. H., Greene, J., & Daniel, D. (2010). What is quality anyway? Performance reports that communicate to consumers the meaning of quality of care. Medical Care Research and Review, 67(3), 275-293. https://doi.org/10.1177/1077558709356300
James, B. C., & Poulsen, G. P. (2016, July 1). The case for capitation. Harvard Business Review. https://hbr.org/2016/07/the-case-for-capitation
MCGUIRE, T. G., NEWHOUSE, J. P., & SINAIKO, A. D. (2011). An economic history of Medicare part C. Milbank Quarterly, 89(2), 289-332. https://doi.org/10.1111/j.1468-0009.2011.00629.x
UIC. (2018, October 8). A shift to value-based healthcare. Health Informatics Online Masters | Nursing & Medical Degrees. https://healthinformatics.uic.edu/blog/shift-from-volume-based-care-to-value-based-care/