Influence of Managed Care Policies on the Activities of Managers - Essay Example

? Managed Care The allocation of tasks in the healthcare services industry is usually based on the competencies and the skills of the individuals involved. However, the performance of participants in such activities cannot be guaranteed, a problem, which becomes more intense in conditions that are characterized by complexity and continuous change. Current paper focuses on the correlation between the policies related to managed care plans and the activities of managers in health services organizations. Emphasis is given on the issue whether these policies can influence the above-mentioned activities and at what level such interaction could be developed. Reference is made to the context and the forms of managed care, as described through the literature and the relevant empirical research. Furthermore, the critical examination of the current activities of managers in health care organizations has led to the assumption that these activities can be influenced by the policies related to managed care but the power of these policies to introduce radical changes in these activities is not standardized, being related to the conditions in the internal and external organizational environment and the personal perceptions/ background of the individuals (managers) involved. In order to identify the potential influence of managed care policies on the activities of managers in health care organizations, it would be necessary to refer primarily to the elements of the managed care framework, as it has been extensively developed across USA. Different approaches have been used in order to describe managed care, probably because of the extension of the particular framework. In accordance with Rickel and Wise (2000) managed care can be described as a framework ‘establishing networks of service providers who agree to the conditions of a contract and choose providers based on the cost, quality and range of services they provide’ (Rickel and Wise 53). In the context of the above framework, a ‘single point of entry, usually a primary care provider’ (Rickel and Wise 53) is necessarily used for arranging the communication between the patient and other specialists (members of the network) in case that such need is identified. Another aspect of managed care framework is described in the study of Edmunds (1997); in accordance with the above study, managed care ‘imposes limitation on utilization of health care services by specifying which practitioners and which services are covered – often, also the number of allowable visits’ (Edmunds 41). In other words, managed care involves in the critical examination of a case (referring to the patient visiting a health services organization) and the referral of the case to appropriate specialists who have the skills and the experience to handle it. Of course, there are chances that the health problem of a patient can be effectively addressed at the first level of the network – i.e. by the primary care provider. Through the above process, the costs related to the health care services are reduced, in the terms that unnecessary expenses on health are avoided, a fact that can significantly benefit the patients but also the state – in cases where medical expenses are covered by the state. From another point of view, the time and the resources spent on each case are appropriately filtered, increasing the effectiveness of health care organizations, which, through the managed care plans can handle more cases, i.e. they are able to respond to the needs of more patients, a fact that increases the effectiveness of the entire health care system. In order to understand the potential influence of the policies of managed care plans on the activities of managers in health care services organizations (HSO), it would be necessary to describe the environment in which these plans are developed; it would be also necessary to refer to the participants, at the level that their decisions and initiatives could affect the activities of managers in HSOs. In accordance with McKenzie and Pinger (2008) the managed health care services are primarily provided by Managed Care Organizations (MCOs) ‘which operate under the same rules as the insurance companies’ (McKenzie and Pinger 430); however, because of the volume of relevant work, the provision of such plans has been also allowed to health care organizations of other forms, such as ‘the Health Maintenance Organizations (HMO) and the Preferred Provider Organizations (PPO)’ (Galanter 21). As for the participants of these plans, these are the persons enrolled in these plans, or else the persons that have rights in the context of these plans, i.e. the patients. The policies included in the managed care plans, as described above, need to address the needs of the participants/ patients. It is on this basis that the influence of the specific policies on the activities of managers of health care organizations will be evaluated. Participants in managed care plans are given the chance to choose among the health care providers most appropriate for their health problem; an indicative example is mentioned in the study of Griffin (1995): the participants in the TennCare plan - the ‘Tennessee’s health care initiative’ (Griffin 326) – are given the option to choose the managed health care network they consider as most capable of addressing their health care needs (Griffin 326). Since they are enrolled in such program, participants have the right to an integrated protection of their health – meaning that not just acute events are handled in the context of managed care, a fact that should be taken into consideration by managers in Health Maintenance Organizations (HMOs) and other organizations that support such plans (Youngberg 25). On the other hand, there are certain issues that have to be taken into account by managers of these organizations when managing a managed health care plan: a) the approach on which the managed care plans are bases is proactive and not reactive (as in acute events, an issue discussed above); participants (i.e. the patients) can ask for health care support even if no acute problem of health is in progress, b) the patients can have access to the data related to their case; there can be no claim that these data are only for internal use (a phenomenon common in health care organizations that deliver common health care plans), c) the health care management system has become ‘decentralized and non-clearly defined’ (Youngberg 25); since the introduction of the managed care plans, the health care organizations that provided, up to then, traditional health care services had to re-organize their policies in order to be able ‘to provide the full range of services required in the context of managed care plans’ (Youngberg 25); in this way, risk in health care organizations has been transferred from the central unit to the particular providers, resulting to following two needs: c1) the tasks necessary in each case need to be appropriately delegated to providers who have the relevant education/ skills, c2) additional education/ training should be offered to providers in order to be able to respond to the needs of the managed care plans (Youngberg 25); d) risks in all aspects of managed care plans are many; from this point of view, these plans can be characterized as quite complex – compared to the traditional health care services plans (Youngberg 25). In the above context, managers in the health care organizations that provide managed care plans should set the following priorities: a) appropriate education/ training programs should be introduced for supporting the providers/ members of the relevant network, b) measures should be taken for the update of existing administrative functions of these organizations, being aligned with the needs of these plans; for instance, patients should have access to the data related to their case, patients should be informed on their rights/ obligations in the context of the managed care plan in which they participate and c) an effective risk management plan should be introduced for handling potential failures related to the delivery of services included in a managed care plan; in fact, emphasis should be given on the management of risks related to these plans since they are quite complex and the chances for failures are many; d) the manager of a health care organization should also periodically evaluate the potentials of the specific organization to respond to the needs of the managed care plan available in the context of the above organization; changes in existing services/ providers should be developed in advance in order to avoid turbulences during the development of the plan. In accordance with the issues discussed above, the managed care plans can influence the activities of managers in health care services organizations but this influence could be made clear mostly in the long term. Of course, the lack of willingness of the manager of a health care organization to support such plans would have immediate effect on these plans’ development; usually, the concerns of managers of HSO regarding the managed care plans are not developed at such point, i.e. up to the prohibition of managed care plans. In this way, appropriate changes are likely to be made on these plans – as also on the activities of managers in these organizations in order for the development of the particular plans, which are of critical importance for the delivery of effective health care services, to progress with no delay. From this point of view, the potential limitations in the activities of managers of HSO, as a result of their influence by the policies related to managed care plans, would be characterized as fully justified and unavoidable. Works Cited Edmunds, Margaret. Managing managed care: quality improvements in behavioral health. Washington: National Academies, 1997 Galanter, Marc. Services research in the era of managed care: organization, access, economics, outcome. New York: Springer, 2001 Griffin, Kathleen. Handbook of subacute health care. New York: Jones & Bartlett Learning, 1995 McKenzie, James, Pinger, R. An introduction to community health. New York: Jones & Bartlett Learning, 2008 Rickel, Annett, Wise, Thomas. Understanding managed care: an introduction for health care professionals. Basel: Karger Publishers, 2000 Youngberg, Barbara. Managing the risks of managed care. New York: Jones & Bartlett Learning, 1996 Younger, Patricia. Legal answer book for managed care. 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