HCM3020 week 5 project
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School
South University, Savannah *
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Course
3020
Subject
Health Science
Date
Dec 6, 2023
Type
docx
Pages
6
Uploaded by ChancellorFreedomManatee22
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Week 5 Project
Juan Padilla
HCM3020 Managed Care SU01
South University
Dr.H
November 27, 2023
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Summary of Medicare and Managed Care:
Medicare is a federal health insurance program in the United States that primarily serves
individuals aged 65 and older, as well as certain younger individuals with disabilities. Managed
care refers to a system of healthcare delivery that aims to control costs while maintaining or
improving the quality of care. In the context of Medicare, managed care involves the use of
private health insurance plans to provide healthcare services to Medicare beneficiaries.
Medicaid and Managed Care:
Medicaid is a joint federal and state program that provides health coverage to low-income
individuals and families. Like Medicare, Medicaid can also utilize managed care arrangements to
deliver healthcare services efficiently and effectively.
Challenges for Medicaid in improving access, quality, and cost of care:
1. Access to Care: Medicaid faces challenges in ensuring adequate access to care due to
low reimbursement rates for healthcare providers, which may result in a limited number of
providers willing to accept Medicaid patients. This can lead to longer wait times and difficulties
in accessing specialized care.
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2. Quality of Care: Maintaining quality of care in Medicaid can be challenging due to the
complex healthcare needs of the population it serves, as well as variations in the quality of
services provided by different managed care organizations (MCOs) that administer Medicaid
benefits.
3. Cost of Care: Medicaid struggles with the rising cost of care, driven by factors such as
an aging population, increased utilization of healthcare services, and the expansion of Medicaid
eligibility. Balancing the need to control costs while ensuring adequate care is a significant
challenge.
Challenges for Medicare in improving access, quality, and cost of care:
1. Access to Care: Medicare beneficiaries may face challenges in accessing care,
particularly in rural or underserved areas where there may be a shortage of healthcare providers.
This can result in long travel distances and limited options for specialized care.
2. Quality of Care: Ensuring consistent quality of care across the diverse range of
healthcare providers and settings within Medicare is a complex task. Coordinating care,
managing chronic conditions, and reducing medical errors are ongoing challenges for the
program.
3. Cost of Care: Medicare faces the challenge of controlling costs while providing
comprehensive care to a growing number of beneficiaries. Rising healthcare costs, advancements
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in medical technology, and the impact of an aging population all contribute to the cost challenges
faced by Medicare.
Future of managed care in Medicare and Medicaid:
The future of managed care in Medicare and Medicaid is likely to continue evolving,
albeit with some challenges. Managed care offers potential benefits such as care coordination,
cost containment, and improved quality outcomes. However, there are also concerns regarding
potential limitations in provider choice, variations in quality among MCOs, and the
administrative complexities of implementing and overseeing managed care arrangements.
For Medicare, the growth of managed care is expected to continue, driven by the
popularity of Medicare Advantage plans. These plans offer additional benefits and integrated
care coordination, which may attract more beneficiaries. Challenges for success include ensuring
network adequacy, maintaining quality standards, and addressing potential disparities in access
to care.
In Medicaid, the future of managed care will likely depend on state-specific policies and
initiatives. Some states have expanded the use of managed care, while others have implemented
reforms to improve care delivery and control costs. Challenges for success include addressing
provider reimbursement issues, ensuring transparency and accountability among MCOs, and
maintaining access to care for vulnerable populations.
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Reputable articles addressing challenges in Medicare and Medicaid managed care:
1. "Challenges and Opportunities for Medicare Advantage Plans" - Journal of the
American Medical Association (JAMA)
2. "Medicaid Managed Care: Challenges and Opportunities" - Health Affairs
3. "Medicare Advantage: Challenges and Strategies for Success" - The New England
Journal of Medicine
4. "The Changing Landscape of Medicaid Managed Care" - Kaiser Family Foundation
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References
Centers for Medicare & Medicaid Services (CMS). (n.d.). Medicare Managed Care Manual. Retrieved
from https://www.cms.gov/Regulations-and-
Guidance/Guidance/Manuals/Downloads/mc86c16.pdf
Kaiser Family Foundation. (2021). Medicare Advantage. Retrieved from
https://www.kff.org/medicare/fact-sheet/medicare-advantage/
Centers for Medicare & Medicaid Services (CMS). (n.d.). Medicaid Managed Care. Retrieved from
https://www.medicaid.gov/medicaid/managed-care/index.html
Medicaid and CHIP Payment and Access Commission (MACPAC). (2021). Chapter 7: Managed Care.
In Report to Congress on Medicaid and CHIP. Retrieved from https://www.macpac.gov/wp-
content/uploads/2021/06/Chapter-7-Managed-Care-June-2021.pdf
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