This paper will provide a comprehensive overview of managed care, primarily on the advantages and disadvantages of managed care organizations.
Over the decades, the United States’ healthcare system has been experiencing challenges. In general, the cost and quality of care has always been considered as the most critical factors that influence healthcare sustainability in the United States and the world, as a whole. As a result, a series of value-based payment reforms have been introduced. For instance, the Affordable Care Act (ACA) of 2010 introduced payment and delivery system reforms.
From a critical perspective, the reforms introduced by the ACA have addressed the long-standing problems which have been posing enormous hindrances to the development of the U.S. healthcare system. Above all, it has enhanced managed care through consolidating care, as well as, addressing the problem of unsustainable costs and uneven quality of care. However, managed care seems to exhibit some drawbacks too.
Table of Contents
- Introduction
- Overview of Managed Care Organizations
- Managed Care Principles
- Managed Care Compared to Conventional Health Care
- Types of Managed Care and what They Are
- Health Maintenance Organizations (HMO)
- Preferred Provider Organizations (PPOs)
- Point-of-Service (POS) Plans
- Advantages of Managed Care
- Decreased Cost
- Accredited Care
- Large In-Network Providers
- Cheaper Prescriptions
- Disadvantages of Managed Care
- Restricted Care
- Out-Of-Network Providers
- Lack of Specialty Care
- Increased Cost of Unapproved Care
- No Access for the Uninsured
- Strict Approval Processes
- Referral Issues
- Summary
Objectives and Key Themes
This paper aims to provide a comprehensive overview of managed care in the United States, focusing on the advantages and disadvantages of managed care organizations. It explores the historical context, principles, and different types of managed care, comparing it to the conventional fee-for-service model.
- The evolution and current state of managed care in the US healthcare system.
- A comparison of managed care and conventional healthcare models.
- The advantages and disadvantages of different types of managed care organizations (HMOs, PPOs, POS).
- The role of managed care in controlling costs and improving the quality of care.
- The impact of managed care on access to healthcare services.
Chapter Summaries
Introduction: This introductory chapter sets the stage by highlighting the long-standing challenges within the US healthcare system, primarily focusing on cost and quality of care. It introduces the Affordable Care Act (ACA) and its impact on managed care as a key reform aimed at addressing these issues, while also acknowledging that managed care has both benefits and drawbacks. The chapter establishes the paper's objective: a comprehensive overview of managed care, emphasizing its advantages and disadvantages.
Overview of Managed Care Organizations: This section provides a historical perspective on the rise of managed care organizations, tracing their origins back to the 1970s and the Health Maintenance Organization Act. It emphasizes the shift from managed care being viewed as an "alternative delivery system" to its current dominance in health insurance coverage across the nation. The chapter highlights the reasons for managed care's widespread adoption, including its role in cost control within Medicaid programs and its contribution to value-based payment reforms.
Managed Care Principles: This chapter delves into the operational principles underlying managed care organizations. It explains how these organizations manage care, emphasizing their responsibilities in coordinating primary and tertiary care, promoting preventative health and education, ensuring appropriate care settings, and aligning incentives to enhance cost-effectiveness. The discussion includes key approaches like cost-sharing and capitation.
Managed Care Compared to Conventional Health Care: This chapter contrasts managed care with the conventional fee-for-service model, highlighting key differences in quality of care, payment mechanisms, and patient choice of physicians. It explains the “capitated” system used in managed care, where a private company assumes financial risk, compared to the conventional model where the state retains financial risk. The chapter also touches upon the state’s role in setting costs and its impact on enrollees' access to care.
Types of Managed Care and what They Are: This section details the different types of managed care organizations, emphasizing their network-based nature and varying degrees of restrictiveness. It specifically describes Health Maintenance Organizations (HMOs), Preferred Provider Organizations (PPOs), and Point-of-Service (POS) plans, laying the groundwork for a more in-depth analysis of their respective characteristics in later sections (which are omitted to avoid spoilers).
Keywords
Managed care, healthcare costs, quality of care, managed care organizations (MCOs), HMOs, PPOs, POS plans, healthcare reform, Affordable Care Act (ACA), Medicaid, value-based payments, cost-sharing, capitation, fee-for-service, access to care, healthcare delivery systems.
FAQ: Comprehensive Language Preview of Managed Care
What is the purpose of this document?
This document provides a comprehensive overview of managed care in the United States, focusing on its advantages and disadvantages. It explores the historical context, principles, and different types of managed care, comparing it to the conventional fee-for-service model.
What topics are covered in the Table of Contents?
The Table of Contents includes an introduction, an overview of managed care organizations, a discussion of managed care principles, a comparison of managed care to conventional healthcare, an explanation of different managed care types (HMOs, PPOs, POS plans), the advantages and disadvantages of managed care, and a summary.
What are the key objectives and themes of this paper?
The paper aims to provide a thorough understanding of managed care, comparing it to traditional healthcare. Key themes include the evolution of managed care, its impact on costs and quality, the differences between various managed care types, and its influence on patient access to care.
What are the main points covered in the chapter summaries?
The chapter summaries provide brief overviews of each section. The introduction sets the context of the US healthcare system's challenges and the ACA's role. The overview of managed care organizations details their historical development and rise to prominence. The managed care principles section explains how these organizations function. The comparison to conventional healthcare highlights key differences in payment, quality, and patient choice. Finally, the section on types of managed care introduces HMOs, PPOs, and POS plans.
What are the advantages of managed care?
Advantages include decreased costs, accredited care, access to large in-network providers, and cheaper prescriptions.
What are the disadvantages of managed care?
Disadvantages include restricted care, limited access to out-of-network providers, potential lack of specialty care, increased costs for unapproved care, limited access for the uninsured, strict approval processes, and referral issues.
What types of managed care are discussed?
The document discusses Health Maintenance Organizations (HMOs), Preferred Provider Organizations (PPOs), and Point-of-Service (POS) plans.
What is the difference between managed care and conventional healthcare?
The main difference lies in payment mechanisms and patient choice. Managed care uses capitated systems where a private company assumes financial risk, unlike the conventional fee-for-service model where the state bears this risk. Managed care also often restricts patient choice of providers.
What keywords are associated with this document?
Keywords include managed care, healthcare costs, quality of care, managed care organizations (MCOs), HMOs, PPOs, POS plans, healthcare reform, Affordable Care Act (ACA), Medicaid, value-based payments, cost-sharing, capitation, fee-for-service, access to care, and healthcare delivery systems.
What is the role of the Affordable Care Act (ACA) in this context?
The ACA is mentioned as a key reform impacting managed care, aiming to address cost and quality issues within the US healthcare system.
- Quote paper
- Patrick Kimuyu (Author), 2018, The Role of Managed Care Organizations within the Healthcare Industry, Munich, GRIN Verlag, https://www.grin.com/document/388764
