Government and Administration: Key and Regulatory Issues in Managed Care - Research Paper Example

Government and Administration: Key and Regulatory Issues in Managed Care Government and Administration: Key and Regulatory Issuesin Managed Care Managed Care is one of the primary concerns for the United States government and it occupies a substantial position in health care reforms. This paper aims to study the Managed Care in USA while focusing on the related legal and regulatory issues. Moreover, the New Healthcare Reform will be discussed. Introduction Managed Care fundamentally relates to those government units which are regulated extensively. However, these regulations are essentially not uniform in their nature. Mostly the state governments focus on regulating the Managed Care Organizations (Kongstvedt P. , 2009). Hence whenever a new law or regulation is passed it is imposed on almost all the operating areas of Managed Care Organization. Different states face entirely different regulation and legal issues depending upon the distinctive nature of their managed care. On the other hand the number of managed care organizations operating in the same state might also experience entirely different set of regulations (Kongstvedt P. , 2009). Before further discussion on the legal and regulatory issues of managed care it is important to identify its role in USA. Managed Care: USA The Managed Care Organization in USA is also known as USA MCO. It is one of the largest private medical and healthcare corporations with the most comprehensive policies and operations. It was established in the late 1984 with a mission of providing healthcare services to local communities (Corporate Information, 2005). Although the organization was formed on national level but the strong management and private ownership gave the surety of required independence. MCO functions in 47 states of America. The organization has a complete list of specialty services while having different ancillary products and panels of medical care providers. It provides distinctive alternatives to its employees including the medical benefits and workers’ compensations (Corporate Information, 2005). Moreover, the working professionals are granted freedom of choice, unique platform which is highly user-friendly, flexibility in working schedules etc. Managed Care Organization has a portfolio of services which are developed considering the needs and requirements of the respective patients and clients (Corporate Information, 2005). The privatized nature of Managed Care Organization gives it immense opportunities for customer partnerships. This subsequently helps in customization of healthcare services which has given an idiosyncratic position to MCO in the market (Corporate Information, 2005). Furthermore, customization helps the management in addressing large scale issues, growth concerns, problems related to diversity and the overall corporate structure. Due to its continuous efforts in becoming better health care services and administration MCO has received the renowned Partnership Award Astra Merck-NMHCC. This particular award was given to the organization for its significant accomplishments in the areas of medical management (Corporate Information, 2005). Discussion Legal and Regulatory Issues with Managed Care Research indicates that there are various regulatory issues with the Managed Care, for instance, the state regulation is applicable to only certain parts of the MCO’s business. These operating business parts usually include the insured medical services of Managed Care Organization (Kongstvedt P. , 2009). Consider an example, if an employee is seeking medical treatment at MCO where he preserves the risk for all the monetary expenses while on the other hand the MCO only gives the basic administrative services. Then in this case the State government has comparatively less authority whereas the regulations of medical services are managed through federal law primarily focusing on the Employee Retirement Income Security Act (ERISA) (Kongstvedt P. , 2009). Researchers and authors have also argued that the legal and regulatory issues in USA are enormous and similar is the case with Managed Care. Civil legal issues comprise the most important elements of the regulatory problems concerning MCO. These can be broadly defined in to two categories (Kongstvedt P. R., 2001). The first category deals with managed care providers and plans while emphasizing over the contracting issues. These also include the legal provisions. The second category typically deals with Managed Care Organizations and their legal liability issues. These might include the activities concerning medical management (Kongstvedt P. R., 2001). Following is the brief description of the legal and regulatory issues with the managed care (Kongstvedt P. R., 2001): Fundamentally the managed health care plan is divided in to two parts. One that deals with the ‘must’ activities and the second is associated with those tasks which are highly desirable. Regulation might be identified when at the end of negotiation the health care facilitator realizes that the basic goals of managed care are not fulfilled. The goals and objectives of managed care are greatly influenced by the state regulations, for instance, the federal government might require a certain clause to be presented in the contract between service provider and receiver. Managed care authorities are needed to make sure that their service providers comprehend these requirements of the state law. The credentials and qualifications of healthcare provider must coincide with the managed care plan. Moreover, the provider should have a valid license. Language also plays an important role in the overall procedures of Managed Care Organization. For example, if in case the hospital is providing healthcare services then the contract will be based upon the specific language identified in the managed care agreements. The relationship between managed healthcare organizations and the service providers is somewhat critical in nature as the contract should not explain service provider as an employee of MCO. This actually gives an independent status to the healthcare providers. Length of the medical contract has to be decided with consensus between MCO and service providers whereas in case of suspension the Managed Care Organization has greater rights. Federal or the State law can affect the procedures and abilities of MCO in case of terminating the healthcare service provider without a properly identified cause. Since MCO has the ability of terminating the provider without any cause then normally the provider should also be given that right. Furthermore, according to some regulations healthcare service providers are required to perform their duties up to a certain time period even after the expiration of their contracts. All of these implications of regulations made in the Managed Care actually lengthened the overall procedure of healthcare services while making it significantly complex in nature. Additionally it makes the procedure more costly as it involves a number of legal contracts. The New Healthcare Reform In order to discuss the legal and regulatory issues with the New Healthcare Reform it is important to first comprehend the idea behind its reformation. The New Healthcare Reform law was actually permitted and signed by the US President Barrack Obama on 23 March, 2010 (Health Care Reform, 2014). This was basically regarded as the victory of democratic political party in America as its associates were struggling to pass the law for decades. Fundamentally the New Healthcare Reform was launched so as to increase the accessibility and affordability of medical services. However, the opponents have also regarded it as the increase in government authorities and power (Health Care Reform, 2014). Thus the New Healthcare Reform met with significant legal challenges soon after its declaration. Few of the regulatory issues are discussed below (Health Care Reform, 2014): Until the end of 2010 US insurance companies were restricted from declining the requests of children having formerly existing conditions. Moreover, insurance plans were required to be updated with an addition of some preventive care services. These primarily included screenings for cancer and diabetes. After the implementation of new order young adults had the authority of staying on their parent’s insurance plan as long as they turn 26 years old. Apart from this the New Healthcare Reform created an entire procedure for external reviews. These actually helped the customers in appealing to the decision of insurance companies. Additionally the law formed a resolution of investing $15 billion particularly for the public health programs. New Healthcare Reform prohibited the denial of coverage to people with pre-existing conditions. Individuals and businesses with above 50 people would have to buy the health insurance otherwise these people would be charged. In addition to these there are few other regulatory issues, for instance, the limits of annual payments are applied on individual cases without considering the family as a whole (Health Care Reform — Regulations on Patient Protections Issued, 2010). Moreover, the New Healthcare Reform has prohibited the health plans related to other social groups. This is primarily based upon the wrong usage of health care opportunities as people tend to seek medical service on behalf of someone else. The reform also commonly recommends a non-grand-fathered plan or option without the element of cost sharing (Health Care Reform — Regulations on Patient Protections Issued, 2010). In response to all these regulatory issues with the New Healthcare Reform different US states entered Lawsuit in Florida on the other hand Virginia filed its individual case. All of these multistate lawsuits criticized the amendments in constitution which require Americans to purchase insurance policies (Health Care Reform, 2014). However, in August 2010 the request made by Justice Department to dismiss Virginia’s suit was rejected by the federal judge. Many of the Republicans actually signified different regulatory issues while stating that the New Healthcare Reform is government’s strategy to take over the health care system. This became a serious issue by the midterm elections of November 2010. Moreover, the CNN poll revealed that 83% of the American population states that the healthcare reform is highly significant for them to make voting decisions (Health Care Reform, 2014). Conclusion The above discussion and research analysis indicates that the idea of Managed Care is becoming more and more complex with the introduction of new health care policies, laws and regulations. One of its significant examples is the New Healthcare Reform implemented by President Barrack Obama in 2010. Many scholars and critics believe that these reformations have actually increased the cost of medical care while negatively encouraging Americans to purchase the insurance policies. Moreover, people believe that it is the misuse of government powers and an extended authoritative practice over the health care system. Managed Care has various legal and regulatory issues and the most prominent problems are based upon contracts between the Managed Care Organization and the health care service providers. It has been noticed that the current regulations give more privilege to the MCO as compared to the service providers. Moreover, the entire concept of Managed Care and its related regulations is found to be less concerned with increasing the opportunities for public care. On the other hand there is very little emphasis over the affordability and accessibility of health care services which actually formed the foundation of New Healthcare Reform. References Corporate Information. (2005). Retrieved March 12, 2014, from USA Managed Care Organization. Health Care Reform — Regulations on Patient Protections Issued. (2010). Texas: Hunton & Williams: Client Alert. Health Care Reform. (2014). Retrieved March 12, 2014, from US News and World Report. Kongstvedt, P. (2009). Managed Care: What It Is and How It Works. USA: Jones & Bartlett Publishers. Kongstvedt, P. R. (2001). Essentials of Managed Health Care, Volume 1. USA: Jones & Bartlett Learning. Read More