Management Analysis of Health Prevention Initiatives - Term Paper Example

? Management Analysis Management Analysis Management analysis of health prevention initiatives, cost containment strategies, quality improvement, and population health focus as they relate to managed care Managed care refers to an arrangement of health insurance that is distinguished by a system of contracted medical suppliers that offer health benefits to a definite population for a predetermined payment. In managed care, health care services are usually included in an arranged care plan by means of a group of primary care doctors who may sometimes be identified as "gatekeepers" (Kongstvedt, 2009). Managed care is thought to be the natural result of measures aimed at curbing the increase of health care costs and the desire to allow all segments of the population to be able to access healthcare. Managed care organizations usually operate as business entities, to make sure that the limited resources are effectively utilized. The original aim of managed care was to stress on the safeguarding of health of the population instead of carrying out expensive interventions once the health of citizens had already been compromised (Risk, 2009). The expression ‘managed care’ speaks for a group of different arrangements that are still being amended and improved for the most part. Four factors are involved in the funding as well as delivery of health care options to the population. These include the suppliers of care, the consumers of the services, the procurer of the care, and the insurer who compensates for care. The expression ‘managed care’ may also be taken to mean preferred provider organizations (PPOs), health maintenance organizations (HMOs), and utilization review. The preferred provider organization (PPO), which works in league with healthcare providers, is responsible for providing covered services for a reasonable fee. Health care providers who operate under definite contracts are identified as ‘preferred providers’. Usually the consumer of the healthcare services and the insurer will give less for healthcare services that they receive from their preferred providers than they would for other providers. PPOs do not decide on the guiding principles that will be observed by preferred providers. The HMO (health maintenance organization) gives preventive health-care benefits to definite populations. The health maintenance organization also provides all the health-care services that are insured at a fixed price in the premium fee. The healthcare consumer has the option of adding co-payments when interested in making office visits as well as other healthcare services. HMOs are also in charge of delivering healthcare through the communication networks built formed among providers. Utilization review refers to the process of assessing the care that is supplied to individual consumers (Kongstvedt, 2009). Utilization review has been utilized broadly in prepaid health-care measures as well as fee-for-service indemnity. Its main objective is to reduce healthcare costs while also enhancing the quality of healthcare. Managed care organizations have historically included the implementation of different prevention initiatives (Risk, 2009). Many MNOs utilize quality improvement and internal performance-measurement systems like the Continuous Quality Improvement (CQI) to test and improve their services. Managed care organizations have become a principal source of health care for publicly funded programs such as Medicare and Medicaid as well as the recipients of employer-funded care. In addition, MCOs stand for systems of organized care that usually concentrate on given social groups and are responsible for supporting objectives like prevention activities. The Managed Care Working Group has been at the fore front of proposing recommendations that can foster the integration into managed care of prevention practices. Cost Containment Cost containment proposals have an effect on health care systems through numerous ways. In the first place, cost containment can change the quality of care that patients receive. In addition, changes in the financial risk can alter the essential ethical foundation of the health care arrangement. Cost containment can also limit access to certain healthcare services for underserved populations such as minorities or low income groups (Fisk, 2007). At present, efforts made to contain costs are focused on ensuring that the cost of health care services is partly met by the providers of that care. In the aim to facilitative this factor, doctors are provided with monetary incentives to function as the gatekeepers of health care services; where they basically restrict access to health care services so that the consumers do not have to deal with excessive utilization. If a third-party payer comes to the conclusion that a doctor has ordered too many health care services, the third-party payer has the authority to financially discipline the physician (Kongstvedt, 2009). This means that physicians will be motivated to only request for healthcare services for patients who are within the stipulated guidelines of third-party payers. This shows that ‘gate-keeping’ changes the aim of the health care system from being the development of the physician-patient relationship to the improvement of the relationship between the third-party payer and the physician. In the final analysis, it is the third-party payer and the physician that will decide on the quality of health care that patients receive as well as whether patients are able to gain access to that care. At present, the healthcare industry is driven by intense competition. Third –party payers will seek to restrict costs by lowering the total amount of money that hospitals as well as doctors receive for the treatment of the ordinary patient (Fisk, 2007). Third party payers can also restrict the type of services that are used by physicians. They can thus compromise the aim of most medical practitioners by affecting the decision making capabilities of physicians. Third-party payers have become the main party in charge of most managed care organizations. This position of authority allows third party payers to campaign for programs geared towards the prevention of injury and the promotion of safety. New systems of compensation ought to be developed in the healthcare system which will address the changes occurring in the relationship between patients, the physicians, and third-party payers.  Quality Issues Managed care schemes offer a wide range of services today in the face of severe resource constraints. This is likely to result in the under serving of the sickest persons in at-risk populations. There is a need for the independent supervision of the care provided by managed care organizations (Fisk, 2007). Many times, the lowered quality of healthcare affects patients in a negative way. Third-party payers are exempted from paying for illnesses that their managed care operations cause, and, subsequently, patients have to deal with uncompensated injuries.  The legal system has to revise this unfair standard and apportion liability to third party payers as well. In cases where the low quality care provided by managed care organizations is to blame, the injured patients should not be left to bear the financial burden on their own. A compensation fund is a just quid-pro-quo for activities in cost containment that can result in the increased incidence of uncompensated medical injuries. This is because it ensures that there is compensation for injured patients, while ensuring that the costs are shared by those who are generating the risk. Population Health Focus Population-based care is based on viewing the consumers of healthcare services in a different way. Potential patients are not seen as just individuals, but as people who have similar health care requirements (Conrad, 2005). While this new perception does not remove from the individuality of the patients, it adds a unique dimension to the whole issue of healthcare as consumers are more likely to benefit from the strategies that are developed for the population segments in which they are part of. Managed care has successfully been able to group panels as well as populations in under different healthcare practices, physicians, and the care of distinct delivery systems. These providers are responsible for the wellbeing of all ill as well as healthy enrollees. However, they are responsible in different extents for the costs as well as resources that come with this care. The tools as well as strategies of population-based care are the result of this system; however, they also bring gains to patients in diverse care systems. Even though access to health care is an essential part of population health, combined policy action in education, income security, housing, the environment, and nutrition/food security is also vital in efforts to provide accessible healthcare for all population groups – particularly the low-income groups. Conclusion In the recent past, managed care has been much maligned as a result of perceptions that cost containment and the empowerment of third party payers will inevitably affect the quality of healthcare provided for most patients, and in particular those from socially marginalized groups. In essence, the competing objectives of generating good profits, containing costs, ensuring good quality of healthcare services, and maintaining and promoting health, are substantial issues that directly affect patient care (Cutler and Miller, 2005). Owing to the fact that the market is the main factor that determines cost containment requirements that are meant to stabilize the system, a relationship between physicians and patients that is based on trust has to be balanced against the other objectives of other parties in the healthcare system. There have to be different strategies developed to ensure that the managed care industry which is based profit maximization as well as cost reduction measures is based on an equally solid ethical foundation. It will be indeed unfortunate if the system’s unique benefits such as disease prevention, the efficient delivery of affordable care, and health promotion are eclipsed by immoral business practices. References Conrad, P. (2005). The Shifting Engines of Medicalization. Journal of Health and Social Behavior, 46(1), 3–14 Cutler, D., & Miller, G. (2005). The Role of Public Health Improvements and Health Advances: The Twentieth-Century United States. Demography, 42(1), 1–2 Fisk, R. (2007). Top managed care contracting clauses: A tool-kit for providers. New York: Hcpro Incorporated. Kongstvedt, P. (2009). Managed care: What it is and how it works. New York: Jones & Bartlett Learning Risk, E. (2009). The new era of healthcare: Practical strategies for providers and payers. New York: Hcpro Incorporated. Read More