Managed Care and Children with Chronic Illness - Case Study Example

 Managed Care and Children with Chronic Illness Managed care has been deemed crucial for utilization by various organizations in counter to chronic diseases that have rampantly affected children in the recent years. The United States has been adversely affected by the rising levels of chronic diseases, thus found it ample for the establishment of regular bodies that ideally manage these chronic illnesses. The recent years have witnessed the rise of various bodies that are concerned with the provision of the managed care services for children with chronic diseases, which are inclusive of HMO and the main Medicaid program that is usually government supported. However, distinct criteria are utilized by managed care providers to distinct degrees of medical care requirements. The recent decades are marked by the attachment of great value to such groups by the states that are faced with high levels of medical needs with an intention of including the poor and the needy in the healthcare programs. Nevertheless, the provision of these services has been limited by certain factors, thus leading to the denial of these services to some children with chronic ailments despite their being needy. Nevertheless, managed care ahs a rationale of providing care services at reduced costs to the patients as well as treatment efficiency measures are of high levels (Perkin, Swift, and Newton 2007). The discussion in this paper is a case study to investigate and establish Managed care and children with chronic illness. The comprehension of this will be enhanced by the study of the scope of the managed care as well as the chronic illnesses that need the managed care. In addition, it is deemed crucial to establish the managed care providers as well as the rationale for such services when provided to patients. More crucial, an explanation will be provided for the criteria which children with chronic disease are covered or denied by managed care (HMO, MEDICAID). Managed care and the ideal providers; Managed care is a term utilized in the US in the description of a diversity of techniques that are put in use with the intention of decreasing the healthcare costs. They are also deemed as a rationale for the provision of benefits of health as well as the improvements of care quality provided by the practitioners. The systems in use are those that imply financing and delivering healthcare benefits and service to those that e enroll. Hence, they are often referred to as healthcare concepts and techniques that are managed by a responsible body. The intentions for the steer towards the utilization of such programs are inclusive of the reduction of the healthcare care costs, some of which are deemed unnecessary via the use of particular viable mechanisms. The provision of economic incentives for care providers as well as their patients, in order to provide room for their selection of programs that are less costly is a long term rationale for the managed care. Specific services review performance and increased cost sharing services for beneficiaries are also the major functions of the managed care. They are also deemed crucial in the control of admissions for patients as well as reducing the lengths f time that patients have to wait for treatments. A variety of settings is deemed vital in the provision of such services, which are inclusive of Health Maintenance Organizations (HMO), Preferred Provider Organizations (PPO) etc (Birenbaum, 1997). HMO is a managed care entity that provides managed care health coverage to its clients, and based in the United States. The fulfillment of such services offer is done via hospitals, doctors or any other form of medical practitioners, all of those that have gained contract with the organization. Its running is based on the 1973 Health Maintenance Organization Act, which requires that public or private organizations with 25 and above employees offer HMO options that are federally certified. The body offers coverage in accordance to its set guidelines such that only medical practitioners who have agreed to work according to those principles are given a mandate. The body accomplishes its goals through the utilization of Medicare programs (Birenbaum, 1997). The Medicaid is a health program that is utilized in the United States by the healthcare settings. It entails the inclusion of families and individuals with low utilizable resources and incomes into a healthcare system that would cater for their immediate treatment requirements. The federal governments as well as the state are charged with the joint funding responsibility for this program as a means-tested one. This system serves US citizens as well as aliens, who are inclusive of low-income earners that have children as well as those people with disabilities. Medicaid has been the largest source of assistance for needy people in regards to funding, as well as and provision of services that are medical-care related (Birenbaum, 1997). Children with chronic illness The period starting 1960 has seen a broad category of judicial and legislative entities develop a concern due to the provision of health services to children with chronic ailments. The recent decrease in the strategies for surgical treatments, procedures for disease diagnosis as well as medical technology have brought in the attention of the needs for children with chronic illnesses. Chronic illnesses in children are caused by a number of overwhelming factors, whether developmental, psychological etc. Three broad non-clinically overlapping groups are found in the categorization of the children with chronic illnesses, inclusive of those with delays in the developmental processes, such as the delays in the general body development and disabilities, and mental retardation problems in addition to sensory impairments as well as disabilities encountered in learning. The children that face medical disorders that are continuous as well as chronic illnesses for instance diabetes; AIDS, sickle-cell anemia etc are also classified as chronically ill and in need of healthcare services. The other category is made up of children that have developed behavioral or emotional challenges and other psychiatric diagnosis disorders. These children are at risk since their treatment requires a huge amount of funds, and whenever raising such funds becomes challenging, their condition becomes critical. Thus, medical care has been seen as an ample strategy that can meet the needs of such children (Birenbaum, 1997). The criteria which children with chronic disease are covered or denied by managed care (HMO, MEDICAID) The criterion for coverage of chronic illnesses by the various setting on the ground of HMO’s is limited to specified coverage programs. These programs act as instruments that define the scope of coverage by the entity. The operations of HMO are generally restrictive on the patients that are to benefit from the programs, thus some children are covered while others are denied coverage chances. One, the restraint of subscriber’s choices to only those doctors and hospitals that are in operation via their networks is a formal routine followed by the HMO. Again, the medicaid patients have an obligation to select a program within the various settings in order that their children with chronic illnesses are covered under specified programs. The coverage of certain children with chronic ailments is highly determined by the economic status of their parents. This is simply because a certain fee is charged to facilitate the managed care programs that are utilized by the various settings. The HMO requires that organizations register with the body about coverage of their employees. The registered organizations will therefore have the children of those working benefit from the managed care programs, while the non-registered organizations will have their employees denied access to such benefits (Harris-Whelming et al., 1995). Additionally, the Medicaid programs funded by the federal and the state are choosy on the type of people to attend to. It is true that the program caters for low income earners as well as the psychologically, mentally as well as the physically disabled in addition to those with chronic illnesses. However, the same via the utilization of the HMO setting does not only consider on aspect as viable enough to prove aid requirements for the available victims. A variety of methodologies is employed in order to determine the extent of assistance that children with chronic illnesses should get. For instance, when the cases of children infected by fatal chronic illnesses like asthma, AIDS are realized to be at higher levels, the consideration must offer such priorities. The rest may be denied the managed care rights at such a time. The payment of particular costs to the HMO may also lead to the coverage and denial chances arising. Some parents that have children with disabilities may not be able to fund these types of programs, thus leading to the denial of their children the access to these medical techniques (Fox and McManus, 1998). Recent studies have also proved that the charges for the managed care meeting the needs of both the healthy children as on average with those of meeting the needs of the chronically disabled. The children from the poor families are also treated in the same manner with those from rich families, since the settings of the programs have not catered for the specialty of some extreme cases of illnesses. The requirement that a patient has to choose a doctor and a hospital from the list of those that have agreed upon the HMO operations and guidelines is also vital in the facilitation for coverage or denial. Whenever a patient is not willing to adhere to such guidelines, it implies denial to the access of such managed care benefits. Thus, a restrictive criterion is utilized in the provision of such facilities, leading to either coverage or denial for children with chronic illnesses (Drotar, 2000). Conclusion Managed care is conduced via the utilization ample techniques in the provision of healthcare to those in need of it. The techniques that are employed entail restrictive measures employment, with an intention of enhancing effectiveness in the coverage schemes. The children with chronic illnesses need be amply covered by these strategies, owing to the fact that meeting doctors in hospitals may not yield excellent results for them. The provision of these services need be as a result of coordination between the state, the employers in organizations as well as parents to enhance the quality of services provided by the various settings, e.g. the HMO. However, research that is more empirical need be carried out to establish the impacts of the managed healthcare on its clients. References Birenbaum, A. (1997). Managed care: made in America. CT: Greenwood Publishing Group. Drotar, D. (2000). Promoting adherence to medical treatment in chronic childhood illness: concepts, methods, and interventions. NY: Routledge publications. Fox, H. and McManus, M. (1998). Improving State Medicaid Contracts and Plan Practices for Children with Special Needs. Journal of Children and Managed Health Care, Volume 8 Number 2. Princeton University press. Retrieved from http://futureofchildren.org/futureofchildren/publications/journals/article/index.xml?journalid=50&articleid=258§ionid=1706. Harris-Whelming et al. (1995). Strategies for assuring the provision of quality services through managed care delivery systems to children with special health care needs: workshop highlights. Washington DC: National Academies. Perkin, R., Swift, J. and Newton, D. (2007). Pediatric hospital medicine: Textbook of inpatient management. PA: Lippincott Williams & Wilkins. Read More