Managed Care in American Healthcare - Research Paper Example

The healthcare market in the United s has been dominated by tremendous growth in managed care and consolidation of the same, both horizontally and vertically. Managed care describes a prepaid health-services plan where physicians are paid their fees for health care services they provide to covered patients. This is so whether the patient seeks healthcare services or not. However, there is a drastic movement of risk from the insurance company to physicians for a patient undergoing comprehensive care. Managed care creates a cohesive relationship between the physician, patient, and payer, which is a crucial aspect in promoting effective healthcare. Historically, health insurers and medical practices accepted the reimbursements offered and signed a signed a multi-year agreement (BBVA Compass Bancshares). Presently, however, primary care and specialty physicians can negotiate their fees if they demonstrate provision of high quality services. The scope of physician /health plan contracting differs in terms their field of expertise, which has seen physicians concentrating in emergency medicine and psychiatry have the lowest rates (Gaynor and Mark 3). Despite this, the basic contract negotiation concepts such as perseverance and concentration of practice protocols still apply. A typical contract-negotiation entails gathering information on all prospective companies and selecting the most appealing according to their consistency on reimbursement. Overhead costs and malpractice liability insurance costs should be considered when setting a policy goal. The US health care system requires that patients have sufficient funds to cater for their medical fees in both public and private institutions. For this reason, medical and health insurance raises significant concerns towards the provision of universal healthcare services. In relation to this, since a large percentage of American lack health insurance cover, the cost of the services rendered tends to be prohibitive for Americans to receive health services (Huynh 2). In addition, the US system utilizes, extensively, the use of payment schemes for health services, such as managed care. The scheme has been in use for a long time and has helped in the delivery of services in an efficient manner. However, strain is experienced by the physician for the role they assume in the provision of healthcare services. In addition, most physicians spend most of their time interacting with health plans to facilitate smooth reimbursement process. This translates to massive loss of working hours, and when converted, practices spend thousands of dollars per physician per year dealing with the influx of interactions with health plans (Casalino et al 533-534). Consequently, physicians as faced with the administrative burden of following up on insurance matters for their reimbursement. This has a crippling effect on physicians on their ability to have increased productivity. In essence, paperwork involved in the health plan contracts between the payers and physicians, does not work in making work easy for the physician. Specialized personnel would be more efficient in dealing with issues that arise from reimbursement concerns, which allows physicians to concentrate on the provision of health services. This would alleviate distraction, strain and the hustle of following up payment. In addition, physicians are tasked with the role of ensuring quality health care is provided. Although the normal ethics and morals of the profession apply, additional guidelines are set to meet the framework within which the patient’s health plan operates. The additional guidelines also act as a checklist to ensure the physician receives reimbursement for his/her services. Despite the checklist being of crucial importance for the benefit of the patient, it places a unique burden on the physician, in that more pressure to the healthcare providers. It is for this reason that the physician is at a disadvantage, owing to the fact that he or she took a financial risk regardless of the professional ethics. Reimbursement for healthcare services is dependent on patients with health insurance, which is usually tied to employment. Some health insurance plans require that the beneficiaries pay a specified amount of cost of their healthcare. Reimbursement in this case refers to compensation for services rendered with regard to healthcare. In most cases, healthcare services are often provided for before payment is made, with the unit of payment is ranging from payment of each service to block payment for beneficiaries over a time. There are two major modes of reimbursements dependent on the health plan, which include fee-for-service and episode-of-care reimbursement. For fee-for-service mode of reimbursement, the service provider receives payment for services rendered as the physician or healthcare organization bills for each service; however, in episode-of-care mode of reimbursement, healthcare providers receive a single lump sum for all services provided in relation to a patient’s condition or disease (Casto and Layman 7). The buy and bill reimbursement scheme work based on the concept of the insurance provider. In such cases, physicians and healthcare providers purchase drugs and other items that are used in the provision. As a result, they end up billing the insurance provider for the cost of drugs. This is to mean that insurance companies work as a form of debt reimburses, where their work is to replace the funds spent by healthcare providers in fulfilling the needs of patients. The buy and bill concept also work for the benefit of the healthcare providers by providing a form of income through the use of incentives found in the buy and bill scheme. In this case, physicians and healthcare providers have the option of choosing and spending funds on costly drugs and other medication before they bill the insurance companies; thus creating room for revenue collection for the said physicians while ruining the cover for their patients and the companies involved. This is because the scheme lowers the quality and cover of the patient since much of the funds are spent in buying expensive medication; which could also be found in cheaper costs than those used. In addition, the buy and bill scheme works in cases where medical and pharmaceutical products are found from different entities and institutions meaning that the products can only be procured by the physicians on behalf of the patient from the manufacturer of distributor since failure to do so affects the quality, cost, coverage and beneficiary equity of the insurance scheme. As a result, insurance providers refund the money of the health institutions after the expenditure is calculated, and funds to be reimbursed are based on the premiums of patients with the cover. Works Cited BBVA Compass Bancshares. Healthcare Industry Spotlight: Negotiating a better contract with Health Insurance companies. 2012. Web. 6 Jan. 2012. Casalino, Lawrence et al. What Does It Cost Physician Practices To Interact With Health Insurance Plans? HealthAffairs. vol. 28 no. 4 533-543. Casto, Anne and Layman, Elizabeth, Principles of Healthcare Reimbursement. AHIMA. 2006. Web. 6 Jan. 2012. Gaynor, Martin and Mark, Tami. Physician Contracting with Health Plans: A Survey of the Literature. 1999. Web. 6 Jan. 2012. Huynh, P. et al. The U.S. Health Care Divide: Disparities in Primary Care Experience by Income. 2006. Web. 6 Jan. 2012. Read More