Health Care Reform Project, Part I

Many have felt that the intentions of this new enactment were to prevent Americans from receiving the proper care that is needed. However, within managed care organizations is the ability to provide all those Americans with better and more affordable care. The formation of managed care organizations grew rapidly during the Great Depression, “not because consumers were demanding insurance against the risk of medical expenses or because nonphysician entrepreneurs were seeking to establish a business, but rather because providers wanted to maintain and enhance patient revenues” (Kongstvedt, 2). There was a major increase to company wide health care organizations when the government decided to enact the federal Health Maintenance Organization Act. This act “authorized start-up funding and ensured access to the employer based health insurance market” (Kongstvedt, 4). Many advocates of managed care organizations like to point out that, “managed care is unique in that it did not arise out of a specific legislative initiative but instead represents a market response” (Health Care Manager, 54). From this we are better able to understand that the wishes of consumers of traditional health care programs felt that something needed to be improved for success. Now that we know where managed care started, we can venture in to how it has evolved throughout the

Health care cost has risen dramatically in the last decade. Health care plans have been forced to look at the quality of health care given by the providers so they can implement certain strategies to help reduce heath care costs. Managed Care describes a group of strategies that is looking to reducing the costs of health care for health insurance companies. (Kongstvedt 2007)

Managed care was established in order to manage health care cost, utilization, and quality (Kongstvedt, 2015). In managed care, health insurance is provided through HMO, PPO, and other types of managed care. It has the potential to reduced health care spending and improved the quality of care. However, despite of its success in improving the quality of care through preventive health care services, chronic disease management program, and so forth, many physicians are reluctant to be part of the managed care environment. Some of the reasons are the impact of managed care to physician’s income and autonomy. Under managed care, insurers have decreased the fees paid to physicians. There are different ways how managed care organizations control costs. One of this is through selective contracting with health care providers and hospitals to lower costs. In selective contracting, health care providers agreed to accept lower prices in exchanged for guaranteed volume of patients under managed care plan (Culyer, 2014). This paper will discuss more issues and trends in Managed Care Organizations such as the rise of Medicaid Managed Care spending, the new Medicaid Managed care Rule, and the collaboration of Managed Care Organizations and Accountable Care Organizations to reduce health care spending and improve efficiency of care.

The article I choose for the Unit 4 Assignment addresses how health care reform is unfinished business in United States. We still have many barriers to overcome if we to provide coverage and access to everyone who cannot afford it. Since I am earning a degree in Health Information Technology and already work in the health care industry this article is relevant to my field of study. This is a hot topic in our country today as it seems that everyone has an opinion on this subject whether for or against the Affordable Care Act. I am including my freewriting on this article below:

Managed care was born out of necessity. It involves plans, members, providers, and payments intertwined, one not working without the other. With managed care came rising health care costs. Utilization management and quality initiatives were introduced to help control these costs. Medicare and Medicaid were also helpful in setting standards of care which reimbursement is based on as well as providing access to health care for more people. Health care costs continue to rise but with passage of the Patient Protection and Affordable Care Act (ACA) the goal is more people will have access to affordable, quality health insurance while reducing the growth in our healthcare spending.

rising health care costs. Managed care can be defined a system of delivering health services in

In 2014, the US entered into the force sensational health care reform of the protection of patients in the United States, which is called The Patient Protection and Affordable Care Act. Under this reform, all the citizens and residents of the country are required to have health insurance. It has also caused many discussions and opinions among people. Supporters of it say that this is a significant step forward, since there is no company that can refuse a person in the insurance policy. However, opponents believe that this reform will only worsen the condition of the Americans. The current health care reform has its drawbacks, such as increased fees for insurance, and the impossibility of choice, therefore, it is necessary for change.

Fundamental changes, one of which is managed care, have been introduced to the healthcare system to improve people’s health and deal with challenges of increased healthcare cost and uncontrolled healthcare utilizations (Steele & Merrick and 2013Shi & Singh, 2015).

In an attempt to understand the impact of managed care in the U.S, I look at the most commonly expressed complaints against the organization. In a survey of consumers, 60% said that managed care had not made a difference in health care cost or had actually been the cause of the increase of health care cost. Managed care has had an impact on slowing the rates of growth in the costs of two major health care producers: hospitals and physicians. Little evidence has suggested that the current reimbursement are inadequate to the care provided. The quality of care is a highly debated issue. Physicians are concerned that the quality of care in managed care organizations may reflect the loss of professional autonomy through pre-authorization procedures.

Citizens in America obtain healthcare either through an employer, Medicare, or ,for the forty-five million, out-of-pocket. The number one in healthcare, Japan, uses the Bismarck model system- healthcare through insurance. America is almost the same, except the Bismarck insurance insures everyone without making a profit. Japan has more privately owned hospitals than America. This model can be funded several different ways for cost-control. The reason we have not changed our healthcare system is because of federal debt. Half of the health care costs are paid by the government. This debt will be America's downfall, but also the healthcare reform it so desperately

Managed care dominates health care in the United States. It is any health care delivery system that combines the functions of health insurance and the actual delivery of care, where costs and utilization of services are controlled by methods such as gatekeeping, case management, and utilization review. Different types of managed care plans came into development by three major factors. These factors include choice of providers, different ways of arranging the delivery of services, and payment and risk sharing. Types of managed care organizations include Health Maintenance Organizations (HMOs) which consist of five common models that differ according to how the HMO is related to the participating physicians, Preferred Provider Organizations

One of the greatest changes in healthcare in the past ten years has been the rise of managed care, much to the displeasure of many patients and physicians alike. Managed care arose out of concern about spiraling healthcare costs and was designed to encourage physicians to give patients treatments that were cost-effective out of their own financial interests. "The consumer strategy was directed at imposing some barriers to use by levying various forms of co-insurance. The most common approaches used either deductibles (where the consumer paid the first portion of the bill a technique familiar in other types of insurance) or co-payments (where the consumer paid a portion of the bill and the insurance company the rest) or a combination of both' (Kane et al 1994). Managed care has given health insurance companies an increasingly significant voice in how treatment is administered and allocated. Managed care has proliferated in the past decade despite considerable criticism of the practice of 'nickel and diming' patients as well as the considerable bureaucratic red tape it is has generated. Also, research indicates that healthy, well-insured patients tend to over-consume care without meaningful co-pays but poorer, sicker patients can be deterred even by moderate co-payments and suffer negative health consequences (Kane et al 1994). However, managed care has not gone away and is a reality that all healthcare

Critics believe that the present functioning of managed-care is degenerative to health care. Managed-care firms control costs by requiring patients to use a “network” of approved doctors and hospitals, and by reviewing the actions of doctors. Patients have to pay more to visit a doctor who does not participate in the “network.” Managed-care firms second-guess doctors, considering only the costs. Patients are often prevented from visiting specialists to reduce costs. A managed-care company might insist that its doctors prescribe inexpensive generic drugs instead of commercial products. Many patients must, also, receive the insurer’s approval before undergoing treatments or operations. HMOs have been criticized for refusing to pay when a patient goes

The focus on this paper is to show how analyzed research on managed care and, the issues of rising exposure to health care costs is threating the wellbeing of American families. Research by Nunez, R., &

The Iron triangle for healthcare consists of cost, quality, and access; these three characteristics when balanced create great healthcare. Managed Care Organizations combine the three to offer consumers with care that is appropriate for their individual needs. Our book describes managed care organizations as “the cost management of healthcare services by controlling who the consumer sees and how much the service cost” (Basics of the U.S Healthcare System, Niles). Taking a look at the history prior to the Health Maintenance Organization Act of 1973 (HMO ACT of 1973) the implementation has been significant in balancing cost, and quality control. Before this Act was signed in to law by President Nixon healthcare costs were determined by fee for service. A fee for service or indemnity plan is a plan that allows the provider to determine the cost of service, this fee for service plan caused for healthcare costs to increase rapidly. An example of this would be going to the doctor with neck pain, being told to stretch then receiving a bill for 25,000 dollars. As could be understood the cost of healthcare had became a problem.