Managed Care Lesson 2:4

Managed Care Plans Differ from one another in some respects, but are all designed to cut the cost of health care delivery. The impact of cost-cutting measures on the quality of health care remains a major point of contention. Advocates claim that managed care plans can deliver medical services more efficiently and at much less expense than traditional fee-for-service plans. Critics argue that necessary, quality medical services are often sacrificed for profit margins.

The following questions are of special concern to patients enrolled in managed care plans: Will the most knowledgeable and experienced physician treat my medical conditions and those of my family? Is my physician too concerned with saving money? Must I fight to get routine procedures from my HMO? What if my HMO refuses to pay for a procedure I need?

Physicians and other medical professionals, administrators of managed care plans, government officials, and HMO members are concerned with such issues as these: Do managed health care and competition actually drive costs down? Do regulations exist regarding patient rights in managed care plans? Do quality ratings for HMOs help consumers? Does managed health care provide higher-quality care than fee-for-fee service?

What exactly IS Managed Care? Managed care health plans are corporations that pay for and deliver health care to subscribers for a set fee using a network of physicians and other health care providers.

Before Managed care Private health insurance policies were traditionally written as third-party indemnity health insurance. Third party means that the insurance company reimburses health care practitioners for medical care provided to policyholders.

Why do traditional fee-for-service health insurance companies now incorporate elements of managed care into their plans?

To confront increasing health care costs, due in part to; Increasingly large awards in litigation An aging population which requires more health care Expensive technology used in modern day medicine.

You need to familiarize yourself with the following terms: Coinsurance Copayment Deductible Formularies Utilization review

Coinsurance The amount of money insurance plan members must pay out of pocket, after the insurance plan pays its share.

Copayment Flat fees that insurance plan subscribers pay for certain medical services.

Deductible Amounts are specified by the insurance plan for each subscriber.

Formularies A plan’s list of approved prescription medication for which it will reimburse the subscriber.

Utilization Review The method used by health plan to measure the amount and appropriateness of health services used by its members.

What are the Types of Managed care Plans HMO IPA PPO PHO POS Open access

Some plans require a set Gatekeeper physician Primary care physician

How does Legislation affect health care plans? Health Care Quality Improvement Act of 1986 (HCQIA) Health Insurance Portability and Accountability Act of 1996 (HIPAA)

Changes to HIPAA tions/HIPAA/2013FinalHIPAARuleSummary/