Managed care
From Wikipedia, the free encyclopedia
The term managed care or managed healthcare is used in the United States to describe a variety of techniques intended to reduce the cost of providing health benefits and improve the quality of care ("managed care techniques"), for organizations that use those techniques or provide them as services to other organizations ("managed care organization" or "MCO"), or to describe systems of financing and delivering healthcare to enrollees organized around managed care techniques and concepts ("managed care delivery systems").
...intended to reduce unnecessary health care costs through a variety of mechanisms, including: economic incentives for physicians and patients to select less costly forms of care; programs for reviewing the medical necessity of specific services; increased beneficiary cost sharing; controls on inpatient admissions and lengths of stay; the establishment of cost-sharing incentives for outpatient surgery; selective contracting with he
alth care providers; and the intensive management of high-cost health care cases. The programs may be provided in a variety of settings, such as Health Maintenance Organizations andPreferred Provider Organizations.[1]
The growth of managed care in the U.S. was spurred by the enactment of the Health Maintenance Organization Act of 1973. While managed care techniques were pioneered by health maintenance organizations, they are now used by a variety of private health benefit programs. Managed care is now nearly ubiquitous in the U.S, but has attracted controversy because it has had mixed results in its overall goal of controlling medical costs.[2] Proponents and critics are also sharply divided on managed care's overall impact on the quality of U.S. health care delivery.
Contents
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∙ 1History
∙ 2Managed care techniques
o 2.1Managed care organizations (MCOs)
∙ 3Types of network-based managed care programs
o 3.1Managed Care in a Public Setting: (MCPS)
o 3.2Health Maintenance Organization: (HMO)
o 3.3Independent Practice Association (IPA)
o 3.4Preferred Provider Organization (PPO)
o 3.5Point Of Service (POS)
o 3.6Private Fee-For-Service (PFFS)
o 3.7Managed care in indemnity insurance plans
∙ 4Impacts
∙ 5See also
∙ 6Notes and references
∙ 7External links
History[edit]
Dr. Paul Starr suggests in his analysis of the American healthcare system (i.e.,steele The Social Transformation of American Medicine) that Richard Nixon, advised by the "father of Health Maintenance Organizations", Dr. Paul M. Ellwood, Jr., was the first mainstream political leader to take deliberate steps to change American health care from its longstanding not-for-profit business principles into a for-profit model that would be driven by the insurance industry. In 1973, Congress passed the Health Maintenance Organization Act, which encouraged rapid growth of Health Maintenance Organizations (HMOs), the first form of managed care.
Managed care plans are widely credited with subduing medical cost inflation in the late 19
80s by reducing unnecessary hospitalizations, forcing providers to discount their rates, and causing the health-care industry to become more efficient and competitive. Managed care plans and strategies proliferated and quickly became nearly ubiquitous in the U.S. However, this rapid growth led to a consumer backlash. Because many managed care health plans are provided by for-profit companies, their cost-control efforts created widespread perception that they were more interested in saving money than providing health care.[3] In a 2004 poll by the Kaiser Family Foundation, a majority of those polled said they believed that managed care decreased the time doctors spend with patients, made it harder for people who are sick to see specialists, and had failed to produce significant health care savings. These public perceptions have been fairly consistent in polling since 1997.[4]
The backlash included vocal critics, including disgruntled patients and consumer-advocacy groups, who argued that managed care plans were controlling costs by denying medically necessary services to patients, even in life-threatening situations, or by providin
g low-quality care. The volume of criticism led many states to pass laws mandating managed-care standards.[3] Meanwhile, insurers responded to public demands and political pressure by beginning to offer other plan options with more comprehensive care networks—according to one analysis, between the years 1970 and 2005 the share of personal health expenditures paid directly out-of-pocket by U.S. consumers fell from about 40 percent to 15 percent.[citation needed] So although consumers faced rising health insurance premiums over the period, lower out-of-pocket costs likely[citation needed] encouraged consumers to use more health care. Data indicating whether this increase in use was due to voluntary or optional service purchases or the sudden access lower-income citizens had to basic healthcare is not available here at this time.[5]

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