Managed Care and Related Concepts in the U.S.
Managed care belongs among the methods of contemporary healthcare delivery. It relies on specialized managed care organizations – integrated into the healthcare system – to guide patients to better health outcomes through individualized insurance plans and transfer service delivery to outpatient settings (Heaton & Tadi, 2022).
Insurance companies and managed care organizations offer a range of health insurance plans. Some are exclusive to a specific healthcare network comprising hospitals, pharmacies, and individual doctors. Some plans do not force their consumers to utilize a specific network, but they nevertheless promote it by footing a more significant portion of the bill. The categories apply to managed care organizations: point of service, exclusive provider organization, health maintenance organization, and preferred provider organization (Heaton & Tadi, 2022). Meeting the diverse demands of the people is the primary objective of the insurance plans’ diversification.
Exclusive Provider Organization and Primary Care Provider
An insurance policy is available from an exclusive provider organization (EPO) that only pays for services provided within a specific healthcare network. That is to say, most EPOs will only pay for out-of-network services in emergencies (kongstvedt, 2019). If not, the user will be responsible for covering the entire cost of any outside-the-network care. Some EPOs may demand that consumers choose a Primary Care Provider for themselves (PCP). PCPs can help the network’s users manage their health issues; however, they are not required to get a reference before seeing another network specialist.
Health Maintenance Organizations
Health maintenance organizations (HMOs) are health insurance types that provide service cost coverage for medical professionals and facilities that have a contractual relationship with the HMO. HMOs, like EPOs, will cover out-of-network services solely in urgent situations. A PCP must be selected for an HMO plan because they will oversee all medical care. The HMO member cannot consult with other experts without a PCP referral.
Moreover, HMOs may geographically restrict their services (kongstvedt, 2019). Nonetheless, unlike other plan types, the costs of in-network services for HMOs are frequently lower. HMOs are renowned for their comprehensive healthcare strategy, emphasizing prevention and promoting healthy lifestyles.
Preferred Provider Organizations
Preferred provider organizations (PPOs) guarantee lower healthcare costs inside the selected healthcare network, just like the two prior insurance plans. However, this time, users must pay more if they use an out-of-network service. On the other hand, there is a much wider variety of networks available to consumers and a much bigger number of networks (Kongstvedt, 2019). Furthermore, PPO members can consult with any expert without a reference, so they do not require the PCP selection.
Point of Service
Point of service (POS) insurance is a hybrid kind of managed care since it incorporates features of HMOs and PPOs. The HMOs passed on to the POSs the necessity to select a single PCP responsible for managing future care and referrals, the smaller network size, and the lower service rates within the selected healthcare network (Kongstvedt, 2019). Users of the plan can choose between in- and out-of-network healthcare providers, much like PPOs do. PPO customers will pay larger shares of the medical services costs of the latter option.
Legislative Influences on Managed Care: Key Policies and Reforms
Overall, the above evidence indicates how managed care organizations have shifted the healthcare delivery focus to outpatient and non-hospital settings. In many ways, this shift can be attributed to the specific U.S. legislature implemented to modify the access, financing, and delivery of care. According to Heaton and Tadi (2022), the acts of the Public Health Service of 1944 and the Health Maintenance Organization of 1973 served as the foundation of managed care practice. Consequently, from the 1970s onward, managed care organizations showcased significant improvement in healthcare outcomes across the population.
The Affordable Care Act (ACA) is one of the more recent laws. It is a component of the national healthcare quality improvement plan, which was implemented in 2009 in response to the unprecedented rapid rise in healthcare costs (McBride & Tietze, 2018). The primary goal is to increase care services while keeping costs as low as feasible. Healthcare organizations hope to change the healthcare system through the ACA to reduce or stabilize healthcare prices. The percentage of Americans without health insurance decreased from 18% to approximately 13% due to regulations on health insurance pricing in particular (Kongstvedt, 2019). Also, it improved the level of engagement between patients and doctors by emphasizing the importance of individual practitioners in health care.
As a result, outpatient care, also called ambulatory care, has proved a valuable addition to traditional healthcare delivery methods. In addition to significant service cost-efficiency, it utilizes a comprehensive approach to patient treatment. In the healthcare field, an emphasis is frequently placed on how to deal with a specific undesired condition.
However, approaching patients this way implies only a short-term solution since it disregards various causal factors. In this context, the health-illness continuum significantly broadens the scope of illness by considering the patient’s health, lifestyle, and psychological well-being before becoming ill. For instance, such a practice is often utilized in HMOs (kongstvedt, 2019).
While psychological factors do not directly cause illness, they significantly affect the body’s natural ability to resist it (Ogden, 2019). In addition, they can impact the patient’s mental health and cause a variety of undesired mental conditions. The same applies to unhealthy lifestyles and habits that increase the risk of poor health outcomes (Ogden, 2019). Thus, to alleviate these adverse effects, managed care plans offer various interventions and healthy lifestyle guidelines to increase health promotion among the population.
References
Heaton, J., & Tadi, P. (2022). Managed care organization. National Library of Medicine. Web.
Kongstvedt, P. R. (2019). Health insurance and managed care: What they are and how they work. Jones & Bartlett Learning.
McBride, S., & Tietze, M. (2018). Nursing informatics for the advanced practice nurse: Patient safety, quality, outcomes, and interprofessionalism (2nd ed.). Springer Publishing Company.
Ogden, J. (2019). Health psychology (6th ed.). McGraw Hill.
Loading...
