The Emergence and Evolution of Managed Care - Essay Example

Managed Care The Emergence and Evolution of Managed Care The concept of managed care is duly regarded as a revolutionary aspect within the domain ofhealth care. Observably, this is an old concept, which has been into the peripherals of healthcare since ancient times. However, it intends to enhance the level of quality care being provided to the patients and also making better use of the available resources in an optimal manner. The concept has been into operation since last 50 years. The idea of managed care has evolved from age old traditions of providing quality care to the people. Correspondingly, the concept draws its roots from pre-paid employer-based health care coverage, which was into practice since 1920. However, during World War II, the market for healthcare coverage started to gain its momentum. With the motive to attract and retain the good workers, the employers started integrating additional benefits for the employees that eventually enhanced quality of their services. This even led towards integrating new concepts of healthcare into the organizations and certainly enhanced the quality life of the employees. Furthermore, the employees even being newly accustomed to the healthcare services accepted the new method of compensation heartily. This phenomenon further developed the ability of the employers to trade in the labor market efficiently, making the concept to be well accepted (Schield, Murphy, & Bolnick, 2000). Correspondingly, with the increasing demand for the healthcare services and their acceptance amongst the employees, the labor unions started demanding for introducing such services as a compulsion for the employers. The loopholes persisted into managed care services were noted to be gaining importance amongst a few of the insurers or employers. Furthermore, these were more evident during the decade bewteen1950 and 1960 when the economy started expanding. The insurers paid off the hospital and the physician charges to the employees under the healthcare service compensation. Observably, the healthcare services cost were paid by the employers for their employees following a procedure of reimbursement. However, the service providers went for incurring extra costs and thus were not controlled by the financial rules and regulations of the market. The boom of economy in 1950 and 1960 were represented by the slack economic seasons of 1970. This change in the economic settings of the society compelled the employers to obtain a detailed view about their overall expenses. Specifically, the compensations and their benefits were crosschecked that evidenced the fact that the different healthcare facilities coined in the mid-century like the Medicare and Medicaid involved excess capacity of costs (Schield et al., 2000). The above stated ill-managed healthcare services were visible during the era and it was even noted that the service providers offering services to various clients were actually involved in charging huge amount of costs for accessing the same. This lack of administration within the healthcare service domain ultimately led towards introducing managed care systems. In this regard, the managed care plans that have been provided with effective utilization control became an eye-catching substitute to ‘indemnity insurance plans’ for many employers. There were several policies undertaken by the government to enhance the ability of the managed care to comply with efficient healthcare needs. Various policies were incorporated within the domain of healthcare to develop the quality of care and even provided efficient support to the employers in the form of lessening costs for maintaining such services. To make transformations in the same, in 1980s, the Health Care Financing Administration (HCFA) incorporated certain changes in Medicare reimbursement policies. Followed by the same, there were various other policies that came into operation including Health Insurance Portability and Accountability Act (HIPAA) and State Children’s Health Insurance Plan (CHIP) among others. More importantly, several organizations switched to the managed care facilities that provided for reimbursement in a much more better way. The individual and the state policies were also engaged in integrating the use of managed care for developing varied healthcare services and meeting the overall needs of the individuals (Schield et al., 2000). The government policies have even reflected on incorporating various concepts of managed care policies. It was noted that most of the programs operating within the system of government are having an uneven distribution of their responsibility. This is evident from the practice in Tennessee that certain Health Maintenance Organizations (HMOs) are eradicating their contracts with TennCare, as the reimbursement practices were not properly covering the costs involved with the similar programs. This development within the field of managed care was further fostered by integration of different healthcare coverage plans. It is even noted that the hospitals entered into contractual terms for developing their overall healthcare needs and delivery systems (Schield et al., 2000). Impact on Access to Care Eliminate Co-payments With the incorporation of the managed care services, several states eliminated the co-payment requirements that were previously present within the domain of healthcare services. Such states argued that the co-payment services, which were prevalent within the society, restricted the advancement of distinct healthcare services. Furthermore, this even blocked the overall goals of the public health programs for providing benefits to the prospective clients. (Mandatory Managed Care, 2000). Assign Health Care Coordinators The further development, which was integrated within the system of healthcare, can be recognized as the creation of a healthcare coordinator position. This inclusion of position certainly enhanced the quality of healthcare, as each new Medicaid beneficiary would be assigned to a healthcare coordinator. According to mental health stakeholders, the healthcare coordinators were viewed to be the promoter for services as well as care instead of considering them to be the gatekeepers who limit care. The coordinators not only assisted in gaining quality mental health services but also enhanced the coordination factor into the same (Mandatory Managed Care, 2000). Allow Any Accredited Provider to Participate States even executed “any accredited provider” language in their respective managed care based contracts. Under this contract, any healthcare service provider meeting the accreditation requirements of managed care and accepting their reimbursement rates were eligible to participate in the managed care system. The states even provided a restriction free participation of the providers, which expanded the beneficiaries’ choice of providers and also increased the capacity of the system to manage the distinct healthcare needs (Mandatory Managed Care, 2000). Encourage Liberal Prior Authorization Policy It was strongly believed that by pre-authorizing a number of initial outpatient services, the administrative bureaucracy and the costs involved with such services could be lessened by a certain level. This was further noted to be enhancing the timeliness of services. The flexibility, which was thus integrated within the system of managed care, even enhanced the satisfaction level of the providers at large (Mandatory Managed Care, 2000). Initiate Outreach Programs Various states were involved in incorporating different measures to initiate the managed care programs. One state argued that it increased the number of beneficiaries accessing mental health services by providing beneficiary outreach programs. The state financed managed care based organizations further developed their contacts with new Medicaid enrollees by periodically hurling newsletters as well as program information to the beneficiaries. This initiative was highly promoted by the state, which resulted in an increase in percentage of Medicaid enrollees accessing mental health services (Mandatory Managed Care, 2000). Develop Rural Services The service development of managed care was largely adopted by several states, as this provided greater financial support to the rural areas. Notably, the rural areas faced different problems because of the presence of inadequate number of providers and services (Mandatory Managed Care, 2000). Share Financial Risk to Encourage Development of Services With the assurance for developing the managed care organizations, the states were ready to provide efficient services. Several states in the initial phase proposed to share financial risks that were probably inherent with managed care organizations. This support from the states allowed the managed care organizations to develop adequate services and programs to meet different requirements of the society. It also allowed the states to test their newly set capitation rates for accuracy without hampering the financial stability position of the managed care organizations. This sharing of risk was particularly helpful to the newly created nonprofit organizations that do not possessed financial reserves to sustain extended operational losses. Thus, is to be affirmed that the shared services certainly developed the capability of the states to efficiently manage their respective mental health programs (Mandatory Managed Care, 2000). References Mandatory Managed Care. (2000). Department of health and human services. Retrieved from https://oig.hhs.gov/oei/reports/oei-04-97-00343.pdf Schield, J., Murphy, J. J., & Bolnick, H. J. (2000). Evaluating managed care effectiveness. North American Actuarial Journal, 5(4), 95-111. Read More