Managed care refers to a set of activities that allow to reduce the cost of health care and improve its quality. Managed care techniques include the regular conduction of utilization reviews, cost-sharing, and the maintenance of provider networks. The critics accuscost-sharing care of the failure to implement the claimed outcomes, such as the higher quality and the lower costs of healthcare. At the same time, the proponents of this system argue that it contributes to the significant rise in efficiency and quality of health care services.
In this context, private insurers play a significant role in the transformation of the healthcare system. First of all, it could be noticed that the practice of implementation of pay-for-performance programs leads to the overall higher quality of services rendered by physicians and other specialists. Apart from that, according to McGinnis, Goolsby, and Olsen (2009), some of the private insurers implement the practice of encouraging the relative improvements in skills and knowledge of physician groups instead of rewarding only high absolute performance. In addition, healthcare transforms due to the implementation of “tiered drug formularies and premium networks” (McGinnis et al., 2009, p. 277). The described innovations made the patients more responsible for their treatment. That is so because the newly implemented system allows consumers to make personal and independent choices concerning healthcare. These choices are made on the ground of the desired benefits and patients readiness to incur certain risks and costs.
The role of nurses in the transformation of healthcare also under no circumstances could be underestimated. Salmond and Echevarria (2017) emphasize that the major contribution of nurses into the coinsion of healthcare is that they act as members of the interproinional team. In other words, the transition from “episodic, provider-based, fee-for-service care to team-based, patient-centered care” leads to improvements in quality and affordability of care (Salmond and Echevarria, 2017, p. 12). What is more, while private insurers are responsible for the shift from the traditional model of healthcare to the pay-for-performance system, it is in the interest of nurses to provide the patients with efficient, safe, and timely medical care.
Finally, it is essential to mention that the responsibilities of nurses are not limited by the bedside care of the patients. Nurses could also contribute to the reduction of costs of the provided healthcare services. One way to achieve this goal is to analyze the symptoms and test results more carefully so as to get rid of some unnecessary medications. The idea is that nurses should assist physicians with the decision-making procedure and diligently report the symptoms, complaints, and changes in health status. The second idea is that nurses might improve communication with the managerial personnel and give them recommendations on the presence and absence of some supplies. This way, they could minimize the spending on purchases of some necessary supplies that might be stocking for a while. Minimized expenses usually lead to lower costs for healthcare.
To sum up, nurses play an essential role in the improvements in healthcare. It is not enough to change the paying strategy or implement some of the managed care techniques. For healthcare to be improved, nurses should act as the leaders who are responsible both for clear communication with the administration and for the provision of decent care for the patients.
References
McGinnis, J. M., Goolsby, W. A., & Olsen, L. (2009). Leadership commitments to improve value in health care: Finding common ground: Workshop summary. National Academies Press.
Salmond, S. W., & Echevarria, M. (2017). Healthcare transformation and changing roles for nursing. Orthopedic nursing, 36(1), 12-25.