Managed care organizations (MCOs) may be able to reduce costs by reorienting provider incentives away from excessive resource use and toward more affordable and efficient treatments. Giving people access to reasonably priced healthcare has also allowed MCOs to flourish, which has reduced expenses. The patient’s access to physicians, specialists, laboratories, and hospitals is governed by these systems. The MCO regulation promotes thorough patient screening and integrated care delivery systems (Bendicksen, L., & Kesselheim, 2022). MCO wants to maintain high-quality healthcare at reasonable pricing. A few of the offered markers of quality of care include access to healthcare, preventative and behavioral strategies, and treatment for acute and chronic diseases (Butler, 2019).
However, aside from highly compensated system administrators and CEOs, the business incentive often explains why patients lack faith in the system and why many peopled are dissatisfied. Other issues include the overuse of emergency rooms, a growing lack of beds for patients, and the provision of follow-up social services to patients (Urmie et al., 2020). These issues are all related to replacing highly trained nursing and medical staff with less trained assistants in order to save money.
The complicated and sometimes disorganized MCO landscape is constantly interacting with APN/APRNs, just like it is for other primary care doctors. The majority of patients treated in nurse-run health centers are either uninsured or self-paying, while the remaining have insurance, which may pay a portion of the cost of their care at nurse-run health centers (Butler, 2019). Attempts to increase access to treatment and enhance the quality of care might be hampered by MCOs’ contractual behavior (Urmie et al., 2020). These regulations make it more difficult for APNs and APRNs to access patients who need care the most and disrupt the continuity of care inadvertently.
References
Bendicksen, L., & Kesselheim, A. S. (2022). Anticipated efficiencies, real costs: Medicaid managed care organizations and the pharmacy benefit. Journal of Managed Care & Specialty Pharmacy, 28(3), 354-361.
Butler, S. M. (2019). How an expanded vision of managed care organizations could tackle inequities. JAMA, 321(21), 2063-2064.
Urmie, J. M., Murry, L. T., Deng, H., & Doucette, W. R. (2020). Iowa community pharmacies’ experiences with Medicaid managed care. Journal of the American Pharmacists Association, 60(4), 624-630.