Managed Care and Integrated Organizations - Essay Example

Managed Care and Integrated Organizations Affiliation: Health care organizations play a very important role in the society. These organizations work towards ensuring that the public is adequately provided with health care services. In this respect, there are diverse and dynamic ways of meeting this objective. Key among these ways is the practice of managed care. The organization and execution of managed care ensures that all the enrolled members benefit from the clearly defined and predetermined health care services. Notably, the effectiveness and efficiency of managed care is critical to the realization of the desired outcomes. Players and participants in the practice of managed care face the challenge of managing and controlling health care costs and utilization. For this reason, there are cost control methods that are specifically designed for managed care operations, namely: choice restriction, gatekeeping, case management, utilization review, and practice profiling or profile monitoring (Shi & Singh, 2004). Among the highlighted methods of cost control, this paper will expound on the choice restriction method. The success of managed care is influenced by diverse and dynamic factors. The common denominator, however, is that managed care is expected to enhance the health-related welfare of all enrollees. In so doing, the overall social welfare of all participants is promoted. In order to realize the desired outcomes relative to managed care, cost and utilization management and control is critical. In this respect, the choice factor in health care provision becomes fundamental to consider. In order to run managed care effectively and efficiently, optimal costs and utilization levels are necessary. To achieve the optimal functionality in managed care, choice restriction is employed. Choice restriction in the managed care context dictates where and from whom medical care is obtained by the patient (Shi & Singh, 2004). What this means is that the patient’s choice of health care provider or physician is limited to the provisions of the managed care plan. In other words, obtaining medical care is limited to the parties participating in the managed care plan (Patel & Rushefsky, 2008). By engaging choice restriction, a health care organization that offers a managed care plan controls overutilization of health care services. In so doing, costs are subsequently managed and controlled. It is obviously expected that this move has its benefits and issues. Notably, such benefits and issues are primarily influenced by the panel factor in managed care plans. Health care provider/physician’s formal affiliation with the organization that executes managed care defines the panel (Shi & Singh, 2004). In the context of managed care plans, the panel can be either closed or open depending on the applicable terms and conditions. The benefits of choice restriction are drawn from the overall practice of managed care. Health care services that are not covered by a managed care plan (closed-panel) aids in utilization control and subsequent cost management. This way, patients make full use of the services availed to them without necessary demanding for more services than they would actually need. Specifically, prior authorization (PA) has been employed in cancer care to control health care service utilization (Fox, 2013). Notably, this is a form of restriction characteristic to managed care. On the other hand, open-panel operations have their benefits as far as managed care is concerned. A plan that provides for open-panel services gives patients more alternatives over and above the already limited choices. This broadens the health care service base, an aspect that works to the patients’ advantage. In the context of cancer care, the same case applies where diversification of managing utilization of oncology agents is advocated for (Fox, 2013). Running managed care has some issues to deal with. To start with, the provision of limited choice may affect some patients negatively. This is in case they need health care providers or physicians that the managed care plan does not provide. In such a scenario, the managed care plan fails to meet its intended purpose of promoting patient welfare. Over and above this, choice restriction may not always control costs and optimize utilization. Managed care restrictions create barriers to health care use, especially in cancer care (Fox, 2013). When barriers to health care use emerge, the cost is transferred to the patient. The same result is realized in open-panel operations. There are inconveniences to deal with as far as managed care is concerned. Over and above that, consumer dissatisfaction with managed care plans is a critical issue subject to choice restriction (Shi & Singh, 2004). In conclusion, the choice restriction method of cost control has its success and failure sides. However, the common denominator is that this method can effectively and efficiently be employed in managed care operations. The idea is to manage and control costs and utilization, aspects that can enhance or destroy managed care. For this reason, it is important to align choice restriction with the desired managed care outcomes. The above discussion can be summarized in a few paragraphs. To start with the cost control method discussed in the paper relates to choice restriction. Any given health care organization seeks to promote the welfare of its patients. In so doing, costs and service utilization becomes critical to account for. In the light of health care service delivery, effectiveness and efficiency is also paramount. By limiting providers and physicians to those participating in the managed care plan, health care organizations streamline their operations so that costs and utilization are managed and controlled. The idea is to ensure that costs are not unmanageable and that utilization remains within the desired levels. In this respect, managed care operations are characterized by notable challenges, benefits and issues. In particular, the benefits of cost control and managed care include streamlined services, access to effective and efficient providers/physicians, low costs of health care and health care plans that foster long term patient welfare. On the other hand, issues related to managed care and related operations include patient/consumer dissatisfaction, high access costs in case of open-panel health care services, and limited medical care choices available to enrollees. It is important to note, however, that managed care remains highly functional, operational, effectiveness, efficient, and patient/enrollee/consumer-oriented. References Fox, L. A. (2013). Managed Care Restrictions: Barriers to Product Use in Cancer Care. Retrieved from http://www.targetedhc.com/publications/targeted-therapy- news/2013/March-2013/Managed-Care-Restrictions-Barriers-to-Product-Use-in-Cancer- Care Patel, K. & Rushefsky, M. E. (2008). Health Care in America: Separate and Unequal. New York: M.E. Sharpe. Shi, L. & Singh, D. A. (2004). Delivering Health Care in America: A Systems Approach. Burlington: Jones & Bartlett Learning. Read More