"Managed care has been the single most dominant force that has fundamentally transformed the delivery of health care in the Unites States since the 1990's". (Shi & Singh) According to the National Library of Medicine, the term "managed care" encompasses programs: "...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 health 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 (HMOs) and Preferred Provider Organizations. (PPOs)
Private health insurance began as a prepaid plan at the Baylor Hospital in 1929. For a predetermined fixed fee per month, Baylor, and subsequently other hospitals, started providing inpatient services. Within a few years, the Blue Cross Commission took over the insurance functions of the hospitals. The growth of managed care in the U.S. was spurred by the enactment of the Health Maintenance Organization Act of 1973 signed by President Richard Nixon. The underlying reason for supporting the growth of HMOs was the belief that prepaid medical care, as an alternative to traditional fee-for-service practice, would stimulate competition among health plans, enhance efficiency, and slow the rate of increase in health care expenditures. The HMO Act required employers with more than 25 employees to provide an HMO alternative if one was available in their geographic area. Premiums are based on contract negotiations between employers and the Managed Care Organization (MCO). Generally, a fixed premium per enrollee includes all health care services provided for in the contract. The MCO functions as an insurance company in that it covers any costs of services provided when exceeding fixed premiums. MCOs provide a comprehensive set of services, including preventive services ambulatory care, inpatient care, surgery and rehabilitative services. Most MCOs have contracts with physicians, clinics, and hospitals while some employ their own physicians on salary. MCOs use three main types of payments arrangements with providers: capitation, discounted fees and salaries. The three methods allow risk sharing in varying degrees between the MCO and the providers. Risk sharing puts the burden on the providers to be cost conscious and to curtail unnecessary utilization's. A survey of physicians and employers reported consensus of the two groups on seven essential features of managed care: cost containment, accountability for quality and cost, measurement of health outcomes and quality of care, health promotion and disease prevention programs, management of resource consumption, consumer eduction programs and continuing quality improvement initiatives. 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 with 90 percent of insured Americans enrolled in plans with some form of managed care. However, there is attracted controversy because it has largely failed in the overall goal of controlling medical costs. Proponents and critics are also sharply divided on managed care's overall impact on the quality of U.S. health care delivery.
Managed Care Museum. 19 Feb. 2009 http://www.managedcaremuseum.com/index.html.
"376 - Statement on Signing the Health Maintenance Organization Act of 1973" The American Presidency Project. 20 Feb. 2009 http://www.presidency.ucsb.edu/ws/index.php?pid=4092.
Shi, L., & Singh, D. A. (2008). Delivering health care in America: A systems approach (4th ed.). Boston: Jones and Bartlett.
Tuesday, February 24, 2009
Friday, February 13, 2009
Our Political and Philosophical Stance
The Obama-Biden health care plan is aligned with what we believe as a group in regards to health care; that all people in this country should have access, and that the coverage should be affordable.
Examples of managed care systems are the multiple Health Maintenance Organizations (HMOs) that are directly connected to hospitals and physicians throughout the nation. When a person is a member of an HMO they will be covered financially for their health care services if they see the doctors and go to the hospitals that are aligned by contract with that Health Maintenance Organization. As health educators we naturally place high value on preventive health care. Studies show that the most socioeconomically under served in our nation, when covered by social health care services like medicaid, utilize more preventive health care services like pap smears, mammograms and prenatal care for women, as well as increased influenza vaccines and diabetic screenings. Many of these State and Federally funded health care plans utilize the HMOs already in place within those states.
Although the HMO model is being utilized within so many federally funded state regulated medicaid programs not all people have access. HMOs and other managed care organizations and systems were set up to manage the rising costs of health care for individuals and employers. The rising cost of health care is making it very difficult for major employers in the United States to compete in a global economy. While managed care systems were set up to slow down rising costs they have not been effective enough.
So many of the Americans that are uninsured are the working poor who either do not have access to health care through their jobs, or can't afford the plans that are offered. President Obama's most recent plan to offer all Americans a publicly funded health care option is answering the call for change in health care. We as a group support this extremely important piece of legislation. While managed care systems tried to slow down costs, they have not done nearly enough to ensure that all people have access to health care.
As a group we do not believe that the health care crisis can be solved privately. Health care is a human right, and needs to be ensured publicly through a federal program like Medicare, but for all people.
Examples of managed care systems are the multiple Health Maintenance Organizations (HMOs) that are directly connected to hospitals and physicians throughout the nation. When a person is a member of an HMO they will be covered financially for their health care services if they see the doctors and go to the hospitals that are aligned by contract with that Health Maintenance Organization. As health educators we naturally place high value on preventive health care. Studies show that the most socioeconomically under served in our nation, when covered by social health care services like medicaid, utilize more preventive health care services like pap smears, mammograms and prenatal care for women, as well as increased influenza vaccines and diabetic screenings. Many of these State and Federally funded health care plans utilize the HMOs already in place within those states.
Although the HMO model is being utilized within so many federally funded state regulated medicaid programs not all people have access. HMOs and other managed care organizations and systems were set up to manage the rising costs of health care for individuals and employers. The rising cost of health care is making it very difficult for major employers in the United States to compete in a global economy. While managed care systems were set up to slow down rising costs they have not been effective enough.
So many of the Americans that are uninsured are the working poor who either do not have access to health care through their jobs, or can't afford the plans that are offered. President Obama's most recent plan to offer all Americans a publicly funded health care option is answering the call for change in health care. We as a group support this extremely important piece of legislation. While managed care systems tried to slow down costs, they have not done nearly enough to ensure that all people have access to health care.
As a group we do not believe that the health care crisis can be solved privately. Health care is a human right, and needs to be ensured publicly through a federal program like Medicare, but for all people.
With an emphasis on primary care, preventive care and access to generic drugs, as well as coverage of pre-existing conditions, we feel that the Obama-Biden plan covers all the important bases. Instead of decreasing the health care options of the insured like HMOs and other managed care systems, President Obama's plan is increasing and expanding options to Americans in health care by allowing them to choose between a federally funded health care option like medicare, and their own private insurance. This plan could open the door to universal health care coverage in this nation, which is excruciatingly overdue. What is most important is that all people have access and are covered.
Author: Sarah UW
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