There has been an increasing amount of health care in the United States that is administered through managed care plans. The term “managed care” evokes negative reactions from health care providers and from the participants. The phrase managed care refers to a variety of techniques for influencing the clinical behavior of health care providers and or patients. The intent of managed care is to streamline services and provide healthcare that is quality and cost effective. The managed care plans supervise, monitor and advise the program to ensure a certain standard of care; they measure performance, and control costs. Some of the managed care plans assist members in staying healthy through prevention. One of the ways the managed care plans control costs is the plans require members to obtain approval before receiving certain services. This will prevent members from obtaining unnecessary services.
The overall goal of the manage care is to place administrative control over cost of quality of, or access to health care services.
One of the advantages of the managed care plans is the negotiated lower rates for basic procedures with physicians, laboratories and other healthcare facilities. This is an advantage for the patient because they can obtain basic healthcare at a lower cost. The patient will know how much the test or procedure will cost before the service is performed. This is especially important for households on a budget. Another advantage of the managed care programs is that it operates with a wide range of physicians and specialists who are connected with the insurance provider’s network. Most manage care plans have a roster of physicians listed by specialty for the convenience of their participants.
There are three basic types of managed care plans:
HMO – This is the most basic and inexpensive of the health insurance plans. HMO stands for health maintenance organization. Under this plan the members must choose a primary care physician or PCP to take care of all their basic needs. The PCP must coordinate all referrals for specialists. The members have to choose a physician in the network to receive the “discount”. This is called in-network. All services provided by physicians outside the network, members will have to pay full amount of the visit.
POS – This plan is also called Point of service plan. It is more comprehensive than an HMO. Some businesses will offer HMO and POS if they know many of their employees have physicians outside of the health plans network. The POS plan still requires members to see a PCP to coordinate the care and must seek referrals. But unlike the HMS members can seek care outside of the plans network.
PPO – This is the most comprehensive plan. It is also called preferred provider organization. This plan gi...
Analysis of Managed Care Strategies and Initiatives
The delivery of healthcare services has been enabled in a way that scarce resources have been put to the best use so as to optimize patient care through an approach involving managed care. Managed care as an approach has principles that form the basis for effective administration ...