Managed Care Backlash - Essay Example

Managed Care Managed Care Backlash: In the 1990s, the widespread evolution of healthcare delivery towards managed care was criticized, which ultimately turned into a backlash on behalf of the legislators, consumers as well as physicians. In this similar context, three particular reasons were mainly identified to raise such discontent that further created unfavorable public opinions towards managed care. One of such reasons includes lack of control over the spiraling expenditures of health insurance premiums. This particular reason made the employees attached with different business organizations in the US to face barriers of free access towards managed care in the global domain. The second reason was noted to be the experience of the people in not viewing any sort of deduction in their respective share of premium costs or a marginal decline in their out-of-pocket expenditures at the time of receiving healthcare. The final reason was related to the hostile nature of physicians towards the principles of managed care. Based on the results obtained from varied national surveys, it was found that the penetration of managed care is negatively correlated with the satisfaction level of the physicians (Landon et al., 2001). Apart from the above stated reasons, there also exist certain other aspects due to which the backlash of managed care can be witnessed. In this regard, the transformation in the ways based on which the physicians had practiced medicine initially with having no responsibility for determining the appropriateness of costs along with utilization was the other factor, which laid the foundation of rising discontents regarding managed care. It was strongly believed that managed care would drive a wedge between the patient-physician relationships. Nonetheless, the little choice of the physicians towards continuing the momentum in getting registered to managed care was also the reason for widespread criticism of healthcare delivery to managed care during the period of 1990s (Shi & Singh, 2011). Regulation of Managed Care The regulation of managed care by the different states of the US can be determined in terms of ensuring the monetary solvency of the distinct organization of managed care including their capability towards covering different enrollees’ risks. Over the previous few years, the regulation of managed care performed by the states was noted to be shifting its focus on maintaining healthcare quality and raising the satisfaction level of the patients. Thus, for an instance, certain states belonging to the US have established regulations as well as passed legislations for ensuring that the patients can possess sufficient access towards consulting specialists through referrals. This can be justified with reference to the fact of passing S. 1052 bill, which has been sponsored by three Senators of the nation. Specially mentioning, this particular bill intended to facilitate the individuals in suing the insurers for taking effective medical decisions in state court. Apart from the introduction of this bill, another bill i.e. H.R. 526 was also passed with the prime intention of providing more limited rights to the individuals in suing their respective health plan (HCFO, 2001). Managed Care Regulation in the Current Era The current policies associated with managed care generally fall under numerous dimensions. These dimensions include taking initiatives or measures for stabilizing the insurance markets, safeguarding the providers from getting any sort of grievance from distinct policies of managed care and standardizing the regulations of patient protection towards enhancing the quality of care. It will be vital to mention in this similar concern that the regulations related to insurance market entail developing plans that disclose valuable information to the customers, establishing the requirements for the renewal of health insurance as well as guaranteed issue and making premeditated efforts towards promoting pooled purchasing of health insurance. On the other hand, the laws associated with patient protection encompass certain regulations with specific objectives. These objectives entail necessitating direct access towards obtaining specific sorts of care, enhancing individual care quality by facilitating easy access towards different services, making valid provisions concerning the intake of prescription drugs and defining the capability of the patients towards filing grievances in opposition to an ineffective health plan. Specially mentioning, the regulations including whistle-blower protections, freedom-of-choice (FOC) laws and AWP laws among others have been fundamentally embraced by the states of the US with the specific objective of safeguarding the providers from diverse managed care organizational policies (HCFO, 2001). Measuring the Impact of Managed Care Regulation It is quite important to evaluate the effects of the regulations related to managed care that have been ratified in the previous years for comprehending the impact of the same. While measuring the impact of managed care regulations, it can be ascertained that the policymakers remain much interested in comprehending the effects of patient-protection legislation in healthcare quality along with costs. It is worth mentioning that certain questions have been raised while assessing the impacts of regulations related to managed care and the legislations associated with the same. In this similar context, such questions can be measured in the form of determining what market failures made the regulatory efforts to become “fix” and the evidences that reveal the existence of any sort of disagreement prevailing within the domain of managed care. With regards to measure the impact of managed care based regulations, it has been apparently observed that extensive level of transformations took place specifically in the US healthcare market in this modern day context as compared to the earlier years. In this context, such changes can be measured in terms of increased level of managed care diffusion and enlargement of different effective health plan networks. These changes certainly made it quite difficult to measure the impacts imposed by the factors concerning managed care regulations implemented in this modern day context (HCFO, 2001). The impact of managed care regulations can be duly measured in terms of assessing the cost implications towards providing hospital coverage. In order to justify this stated context, the discharge data of the mothers as well as newborns in a hospital in Illinois, as a case study, can be taken into concern for discussion. Observably, most of the women i.e. the mothers remained fewer days in the hospital as compared to the legislated minimum and in relation to this, most of the newborns who got released from the hospital remained unhealthy with nearly 2 percent of the same being admitted in the initial two weeks of life. By considering this illustrated percentage, it has been concluded that if 10 percent of women i.e. the mothers increase their stay to the legislated minimum, then the additional charges of the hospital would surpass savings unless 100 percent of re-admissions were evaded. These implications of costs eventually signify the impact of managed care regulations particularly on different healthcare based organisations. It can be apparently noted that various researches are being conducted to evaluate state based managed care regulations towards protecting the patients by developing effective plans and enforcing varied sorts of patient protection related laws. It has been ascertained that in order to measure the actual implications of managed care regulations, the researchers of this modern world will mainly adopt certain quality measures. These measures include forming, developing along with preserving an “index of regulatory intensity” based patient protection laws, learning more about the complexities persisting in executing as well as enforcing laws of patient protection that formulate by different states and determining whether such laws have attained their respective intended effects with evading unintentional consequences (HCFO, 2001). Specially mentioning, in order to make a comprehensive understanding about measuring the impact of managed care regulations, modern researchers usually make an attempt to study the association prevailing between the increased level of introducing states as well as federal based regulations and the decisions of the employers towards self-insuring their respective managed care offerings. Apart from this, researchers endeavors to test the level up to which the drop in percentage of employees who have been offered with self-insured managed care plans might get related with the passage of Health Insurance Portability and Accessibility Act (HIPAA) and other related mandates despite the existence of Employee Retirement Income Security Act of 1974 (ERISA). It is projected by various researchers conducting study on the similar field that regulations related to managed care can be developed and executed effectively by providing valuable information to policymakers about the association persisting between self-insured employer plans and the market of health insurance (HCFO, 2001). Lessons Learned The evidences pertaining to managed care reveal that it imposes positive impact on controlling maximum growth of the rising healthcare expenditures without affecting the healthcare quality to the fullest possible extent. The factor concerning managed care has been a debated topic in the US in recent times. It will be vital to mention that the way based on which the regulations of managed care have been implemented in the nation, these seem to be acted as the products penetrated into the business markets. It can be revealed that the implementation of varied regulations associated with managed care has promoted innovation in the context of developing healthcare facilities and determining about how incentives can get aligned in every level of global healthcare system. It is worth mentioning that the tools developed by managed care are deemed to be applicable in public as well as private healthcare systems. It has been apparently observed that several healthcare systems, which are publicly funded, are involved in the procedure of segregating funding from purchasing of varied healthcare services. This particular practice might provide significant benefits to the techniques of active purchasing executed in the US. It must be consider that within the periphery of imposing certain limitations by the constrained resources, the factor concerning managed care is able to adopt and utilize practices that tend to enhance the efficiency of the physicians and hospitals as well (Sekhri, 2000). Apart from the above discussed, lessons learned about the regulations of managed care, also lay certain other attributes that clearly depict the impacts of the same, which have been elaborated in detail hereunder. Plans willingness to participate. Notably, several states in the US have encouraged Health Maintenance Organizations (HMOs) to partake in distinct programs of managed care such as Medicaid. The factors concerning greater risk protections, favorable market rates and potential market share among others ultimately affecting the willingness of HMOs to participate in such programs (Anderson & Fox, 1987). Nature of competition. It is projected that the effective programs of managed care like Medicaid particularly those, which are focused on developing prepaid health plans are likely to produce competitive dynamics in private along with public sectors. It can be apparently recognized that the HMOs compete through several ways, specifically in terms of ascertaining healthcare costs and determining the scope of benefits (Anderson & Fox, 1987). Medicaid populations with special needs. The enrollment of Medicaid populations in HMOs is identified to get differentiated extensively from the enrollees of private sector based on the ground of serving special needs. Justifiably, for meeting the special needs of the populations including pregnant women and children among others, the Medicaid enrollees tend to offer quality on-going care to them. In comparison with the above stated context, the enrollees belonging to private sector focus on covering preventive services along with delivering proper care to the above stated populaces (Anderson & Fox, 1987). Rate setting. While partaking into the programs of managed care like Medicaid, the HMOs at certain times obtain a capitation rate set of 90-95 percent on a monthly basis. However, certain problems are observed to remain within rate setting that include making effective decisions and lack of accessing actual data among others that require to be mitigated for deriving positive outcomes (Anderson & Fox, 1987). The above discussed transformation in the settings of managed care programs has profound implications on healthcare cost-containment in the US in future. This certainly acted as one of the prime drivers of healthcare policy along with disbursement in the US, which opened newer ways towards modernizing such programs with the prime intention of providing effective as well as quality care to the patients. In the context of explaining the lessons learned from the implementation of varied managed care related programs and regulations, it can be affirmed that development in the domain of information infrastructure has become an influential part towards implementing effective consumer driven plans. This execution of consumer driven plans is identified to be augmented on a continuous basis in the US, which can be measured in terms of increased level of participation made by the consumers and employees in the above stated context (Lagoe et al., 2005). Similarly, rise in the annual percent change in healthcare spending in the US is also witnessed, which can be better understood from the following depicted graphical illustrations: Source: (Lagoe et al., 2005) Source: (Lagoe et al., 2005) Recommendations: By consideirng the fact that different programs related to managed care like Medicaid are expanding their services towards providing several significant advantages to benefeciaries, there lays a requirment of developing the same to ensure that the enrollees can get easy access towards high quality medical services. In this similar context, several suggestions have been provided so that the services, plans and programs related to managed care can get developed by a considerbale extent. Thus, one of such recommendations can be reckoned as providing greter access to the covered services by the managed care plans of Medicaid by entailing varied applicable provider specality types. These plans are ought to make sure that a preventive, specialty and primary care services are offered to the enrollees within a stipulated timeframe. Apart from this, such plans must account for determining the geographical location of the enrollees as well as the providers with ensuring enhanced levels of transportation. It is projected that the regulations associated with plans of Medicaid should be sufficient enough to provide better treatment to the patients in terms of reasonable travel time or distance with due consideration on the diverse geographical locations. In terms of providing recommedations, it is to be affirmed that the states present within the US possess authority to formulate and execute plans based on the availbaility of providers on specific locations (Coursolle, 2013). Apart from the aforementioned aspects, delivernace of timely access to different services by the managed care plans of Medicaid could also be taken into concern for deriving varied positive outcomes. It will be vital to mention in this similar context that such plans need to follow certain specific requirements in order to fulfil the objective of offering enrollees with timely access towards different services. In this regard, such requirements mainly comprise of factors such as meeting the state standards with respect to timely access to services as well as care, considering care urgency, making the necessary services to be acceesible when needed and adopting corrective measures towards mitigating any sort of issue. It is worth mentioning that providing greater access to out-of-network services, only if no in-network providers are accessible by the managed care plans, would prove to be quite benefecial in long run. This particualr initiative would certainly result into facilitating the enrollees to access their required services along with care without necessitating any sort of prior authorization (Coursolle, 2013). Most importantly, the plans of managed care related to Medicaid must offer assistance to the enrollees for accessing the required services associated with disbailities. In this simialr context, the determination of physical accessibility is deemed to be an influential factor towards providing significant benefits to the enrollees in long run with improved medical as well as treatment facilities (Coursolle, 2013). Conclusion During the later stage of 19th and the commencement of 20th century, managed care evolved as an incorporation of insurance function with utilizing the conceptions of ‘prepaid group practice’ and also ‘contract practice.’ It is worth mentioning that though the practice of managed care and its distinct regulations have emerged as a dominant medium based on which a major percentage of the Americans receive quality healthcare services, these are still being thwarted by the policymakers, consumers as well as the providers or the enrollees. It is to be affirmed that the growing standards of managed care is duly considered to be one of the prime factors, which formed an effective incorporation of varied quality healthcare services amid the healthcare providers. In relation to the above context, though the functions and the roles played by HMOs remain unclear to a certain level, these sorts of organizations remain envisioned towards attaining certain speciifc objectives. These objectives mainly include controlling excessive healthcare related costs and maintaining quality of care among others. Thus, in conclusion, it can be affirmed that the formation of an ironic collaboration between the providers or enrollees and managed care along with varied regulations will certainly appear as the next biggest trend of American healthcare system. References Coursolle, A. (2013). Network adequacy in Medicaid managed care: Recommendations for advocates. Retrieved from http://www.healthlaw.org/issues/medicaid/managed-care/network-adequacy-in-medicaid-managed-care#.VQKZy9KUfQN HCFO. (2001). Foreword. The Challenge of Managed Care Regulation: Making Markets Work? 1-13. Landon, B. E., Zaslavsky, A. M., Beaulieu, N. D., Shaul, J. A., & Cleary, P. D. (2001). Health plan characteristics and consumers assessments of quality. Health Aff (Millwood), 20(2), 274-286. Lagoe, R., Aspling, D. L., & Westert, G. P. (2005). Current and future developments in managed care in the United States and implications for Europe. Health Res Policy Syst, 3(4). Shi, L., & Singh, D. A. (2011). Delivering health care in America. US: Jones & Bartlett Publishers. Sekhri, N. K. (2000). Managed care: The US experience. Bulletin of the World Health Organization, 78(6), 830-844. Read More