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Managed Care

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Managed care refers to a range of health care systems that are used to reduce the cost of health benefits provision and improve the value of care. It could also be a health insurance plan that covers the enrolled persons through co-copayment or co-insurance. These are programs that are used to lessen needless health care costs using various systems such as economic inducements for doctors and patients to identify more affordable types of care and improved beneficially cost allotment. It ensures a balanced billing to every member of the society irrespective of their status. Managed care was facilitated by the ratification of the Health Maintenance Act of 1973. Though the techniques were introduced by the public health preservation organizations, different private health benefit schemes are now using them. Managed care is supposed to suppress medical cost by for instance, reducing avoidable hospitalization and causing the healthcare field to develop efficiency and competitiveness. When a person enrolls for the managed care plan, he identifies a doctor who is referred to as the primary care provider who takes over the responsibility of coordinating his health care  

Managed care has played a significant role in making quality healthcare reachable by many people across all economic status. Let us examine how this system has achieved success in the society as well as its failures. There are several managed care systems that have been employed by experts in reaching their goals. These include capitation, which involves paying a doctor a certain fixed amount for each sick person irrespective of the cost and time needed to treat a person. In this system doctors agree to charge a certain reduced amount from their normal charges in substitute of giving medical care to a group of sick people. Capitation is an example of managed care operations that try to keep the cost of healthcare at manageable level. Other systems that seek to improve the quality of healthcare for example clinical procedures that try to change the clinical administration of certain specific health issues such as high blood pressure are also regular managed care practices.      

What are the weaknesses of managed care? Since managed care seeks to reduce cost and time of treating a patient and on the other side improve the healthcare standards, critics have argued that it may not reach its intended goals. The technique has therefore achieved some success but has also experienced its fair share of shortfalls. Among its shortfalls is that most of the managed care wellbeing plans are provided by commercial firms, consumers argued that their cost control efforts were more geared towards saving money that providing proper health care (Nation’s Business, 1998). Consumers felt that manage care reduce the amount of time physicians spent with patients. This made it difficult for patients to get doctors’ attention thereby failing the technique’s intended purpose. Dissatisfied patients and lobby groups argued that managed care systems were managing costs by refusing necessary services to patients, including in fatal situations or by provision of low substandard care. Due to the increased criticism, many states passed legislations regulating the standards of managed care offered to patients. In addition, insurance companies answered the public and political demands by starting to give other plan options that had a wider range of care networks. 

Managed care has a wide range of structures and names. One of the structures is the risk based Managed Care Entities (MCEs) which are employed in providing and managing benefits. In a contract that covers the full risk, MCE agrees to offer all benefits on the basis of per month per member which is known as complete capitation. In case the enrolled person uses the services that go beyond the capitation payments, the additional costs are met by the managed care plan. If the case is the other way round where the enrolled person uses less, the plan either reinvests or keeps the unused money. If the contract is partial, the plan is usually paid beforehand to deliver a section of services such as crisis services or mental health case while the rest of the services are given on a fee of services basis. In some cases, an incomplete plan could be at risk for costs or gains that go beyond a predetermined edge more than or less than a set cost. Another structure is the Administrative Services Organizations (ASO) which governs benefits and claims for a set administrative charge while carrying petite or no risk at all for the price of delivering care.

As much as all the stakeholders may want to control the costs of health care using managed care system, doctors are the ones who can make this fact more real. This is because managed care is configured around different incentives to promote the practice of affordable medicine and to reduce differences in medical practice patterns. This means providing quality healthcare and at the same time reducing the recourses needed and in this case money. More often than not, efficiency is capitalized on by increasing production while managing cost. Therefore, managed care may necessitate performing more using less time per every sick person, less expensive drugs as well as less expensive diagnostics examinations and treatments. All these operations or tasks are carried out by the doctor and therefore he is the only one who can determine whether they are achievable or not.  

Incentives in monetary form are often used to influence doctor behavior and may involve rewarding doctors who exercise medicine prudently by giving financial rewards for example bonuses. Those who carry out unnecessarily numerous procedures and are not cost efficient on the other hand, may be reprimanded by preservation of bonuses or parts of their income.  Inducements which are not in money form may be used by superiors to pressurize those who are not able be accountable to the financial interests of their employer.  These fiscal and non fiscal incentives raise the moral concern that doctors may compromise patients’ support in order to realize cost savings. There is also the issue of trust between patients and physicians. Many are alarmed that managed care could weaken patient –doctor relationship by eating away at the patients’ confidence in their doctors thereby minimizing the time doctors spend with sick people and curbing patients’ access to doctors. Managed care has been known to alter the way relationships between doctors and patients begin and end. Health preservation organizations for instance only pay for medical care that is provided by their doctors. Annihilation of patient –doctor relationship can in addition occur without the choice of the sick person. This occurs for instance where employers change health plans and hence employees have no other option but to cut ties with their doctors. Further more, some types of managed care develop a monetary incentive for physicians to spend very little time with every individual patient. For example, in the preferred provider arrangements, doctors may reimburse for cheap costs for attention by attending to many patients. This could be detrimental since it reduces the available time to talk about patients’ problems, explore different treatment options as well as maintain a significant relationship with patients.    

How can managed care affect the facts stated above? As we had mentioned earlier the success or failure of the managed care techniques largely depends on doctors. Since managed care is supposed to structure ways of reducing the cost of medical care, doctors should be able to draw a line between moral responsibility and money. By this I mean, doctors should not ignore patients’ need for attention just because they are on a managed cares scheme. Like we have mentioned above, some schemes authorize the doctor to give the patient a certain amount of time after which he must proceed to the next patient. Critics of managed care have always raised issues with such arrangements arguing that this does not give priority to the patients well being. Another problem that managed care experts are working on is the quality of health that patients get. There is a probability of compromising on the standards of treatment as people try to minimize cost. According to the American Journal of Medical Care there has been unsuitable antibiotic prescription to patients under managed care suffering from influenza (Misurski, Lipson & Changolkar, 2011). This means that experts in the industry must ensure that high quality of medication is maintained. It must be understood that no amount of money can be compared with the safety of a person and therefore we cannot afford to save money at the expense of human lives. As much as we may want to save on medical cost, we may end up loosing more when lives of people are put on the balance. 

Let us now look at how well managed care has achieved its objectives. The purpose of managed care has been to ensure quality health care, at an affordable cost with easy accessibility to all members of the society. According to the available information, managed care has received good response from the general public as well as the authorities. In the US for instance, 90% of all the people who are insured are now under the enrolment of a certain from of managed care (America's Health Insurance Plans, 2007). This shows that the plan is working well in the public domain and therefore many people have preferred to enroll. Through the use of various points of service it is possible for the enrollees to choose the system to use up to the point where the service is available.  Various techniques have been put in place to ensure that the plan achieves the success it is currently enjoying.  These include selecting providers that supply a comprehensive collection of medical care services to the enrolled individuals. This means that the providers have to be scrutinized and vetted properly before being allowed to operate. This ensures that only legitimate and capable providers get to offer the plans. Another technique that has been used is the official utilization appraisal and quality enhancement programs. The quality improvement programs are geared towards improving the providers’ services to meet all the required standards as well as the new challenges that could face the plan over time. The providers are also supposed to review their plans to ensure a continued improvement program to fit every enrollee. Another method is the stressing on the importance of preventive care. This system seeks to educate the general public on observing the necessary measures that prevent new infections. These include encouraging people to observe hygiene, taking precautionary measures when using machines or properly dressing to keep warm just to mention a few. All these measures and others help in avoiding cases of illness or diseases that could necessitate one to get the attention of a physician. This meets the objective of managed care by ensuring that the visits to a doctor or administration of medication are kept at the minimal level and hence reduce the cost of health care. In addition, there has been economic incentives that encourage those who are enrolled in a program to use care efficiently.  This could be through the providers or even through other health institutions. Some provider associations also allow negotiating of favorable fees in order to encourage new enrollees to get into the program. A survey that was done in 2009 by the America’s Health Insurance Plans discovered that patients who decided not to use managed care program providers were sometimes charged exceedingly high prices (Gina, 2009). This could also be tact to encourage people to enroll for the program. All these techniques have seen the number of people in the managed care rise steadily over the years.  

In summary, the general results of managed care have remained widely debated. The system seeks to reduce that cost of health, increase the quality of treatment and improve accessibility of health facilities to the public. Managed care received a lot of opposition from critics in the beginning who argued that the system seemed to prioritize the issue of costs rather that the more important issue of good health. Hospitalists were accused of not giving enough attention to patients under certain types of the program even during fatal situations. They believed that the scheme had not achieved its intended objective on the quality as well as the cost of health. However, with the different techniques that have been employed, managed care has been able to get impressive success and hence about 90% of the US insured population is enrolled in a certain type.

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