The term managed health care can be described as a program that ensures appropriate health care is provided to patients, at affordable cost and high quality. According to American Heart Association (2009), the goals of managed care are: to deliver high quality care at minimum cost, deliver medically necessary and appropriate care as per patient’s condition, and to ensure care is delivered by appropriate provider and at appropriate setting. It employs cost containment system to ensure enhance utilization of health benefits by regulating the type, frequency and level of treatment offered to the patients, as well as controlling the access to care and reimbursement requirements for services.
Just like any other project, managed health care has had its own share of criticism. Osborn (2004) claims that major patient complaints revolve around quality, customer service and cost. Some of the complaints that patients have aired include the fact that they are never allowed to see a doctor of their choice unless he is in their network, while in a number of the cases, there is shortage of doctors due to transfers, retirement or even death, thus affecting the quality of service.
Patients also complain that they fail to get satisfactory services from the program, considering the time it takes to get the service and the behavior of the service providers. They go to an extent of comparing the services they receive with services from other service industries. Another argument is that it has contributed to an increase in the costs of health care putting in mind that, patients like to enjoy the true worth of what they pay for the service.
Consolidated Omnibus Reconsolidation Act of 1985 (COBRA)
Cobra is a law that was passed by the United states congress and signed by president Reagan, and was meant to mandate an insurance program in order to give some employees the ability to enjoy health insurance coverage even after leaving employment. According to United States Department of Labor (n.d), it was an amendment of Employee retirement Income Security Act of 1974 (ERISA), and it deals with a number of issues including but not limited to private pension plans, disability insurance and job loss temporary insurance plans.
COBRA offers a continuous coverage plan that should be afforded to the employees who may otherwise lose their group health plan when a specific event occurs (United States Department of Labor, n.d). in order to enjoy the benefits of COBRA continuous plan, the employee must first be covered by group health plan and a qualifying event must occur which may include termination of employee due to reasons not related to gross misconduct and loss of employment hours. In addition, the employee should be a qualifying beneficiaries – he must have been a member of a group health plan when the at the time of occurrence of the qualifying event.
According to United States Department of Labor (n.d), COBRA Continuation plan is more attractive since it is less expensive than what most of the employees would charge for the continuation plan. The American Recovery and Reinvestment Act of 2009 include 65% employees for COBRA enabled insurance for up to nine months after involuntary termination, or if the employee has no other group sponsored healthcare and also if the employee is eligible for COBRA.
Employee Retirement Income Security Act (ERISA)
According to United States Department of Labor (n.d), ERISA is a “federal law that sets minimum standards for voluntary pension and health plans to protect individuals in private industry”. It regulates the health plans by providing information to the beneficiaries; establishes processes for participants to air their concerns; regulates the providers of the plans; and ensures participants and managers understand their obligations in the plan. It was enacted and passed into law in 1974 (United States Department of Labor, n.d).
It is from amendment of ERISA, that COBRA continuation plan was established as well as other health acts in order to expand coverage to certain specific cases. Exempted from ERISA plan are group health plans established by government agencies and churches as well as plans that cover aliens or nonresidents (United States Department of Labor, n.d).
The Gag Clause Laws
According to United States Department of Labor (n.d), these are clauses formulated by managed health care organizations that prohibit the physicians from discussing all the treatment options with the patient. Even though the state could be trying to limit the use of such clauses, the MCO can still control the physicians actions, since every health service contract signed by the physicians include a ‘termination without cause’ clause which allows the managed care organization to fire the physician with or without cause.
These clauses adversely affect both the patient and the physician because the new physician has to work hard towards creating a new relationship with the patient, which may turn to be a real challenge. In addition, the patient whose physician has been deselected may not readily get a replacement; the patient may also have negative perception on the new physician’s profile. Moreover, patients who are very sick or poor, and have not been assimilated into the health care system, may present a very complicated financial task (United States Department of Labor, n.d).
It’s therefore important that communication be allowed between the physician and the patient, to enable the patient choose his preferred health care. The ‘termination without cause’ clause should be replaced by a ‘termination with hearing’ to make it clear that the physician is not terminated due to quality of care reasons.
References
American heart association. (2009). Managed Health Care Plans. Web.
Osborne, L. (2004). Resolving patient complaints: a step-by-step guide to effective service recovery. MA. Jones & Bartlett Publishers.
United States Department of Labor. (N.d). Consolidated Omnibus Reconsolidation Act. Web.