Understanding the Future of Managed Care

At one point, managed care was the viewed as a resourceful tool in efforts to help assist employee, physicians and hospitals with quality health care, while controlling the cost of medical care in the United States. Over the past 30 years, managed care has been in the limelight of health insurance, as a dictator of how it will pay for medical bills. There have been many factors playing a role with managed care over the years.

For example, due to the slim selection of options that are available with physicians in rural areas, and limited physicians to choose from, does this compromise the quality of care of each member or does this cut off services for members that are critically ill? Managed care continues to affect not just members in the work force but also it affects disabled members, the elderly community, and young children covered under Medicaid. The struggles to find a solution to all the concerns as it related to Managed care would continue to be an ongoing concern.

The future role of government regulations, including ERISA and HIPPA will continue to play a role as it relates to managed care, and the protection of the rights of employees. The cost containment of health care benefits and the high deductibles are an ongoing topic for discussion as to how it affects employees and their medical needs going unmet for the lack of revenue to pay for the deductibles. In this paper discussion related to concerns, evolving around managed care would be discussed. The future for managed care would be outlined in depth, and the need for managed care would be mentioned. Managed Health Care Quality

The initial beginning of Managed Healthcare started in the United States with the purpose of improving the medical system. Since the beginning, which has been over 3 decades, research has indicated that the goals are being reached. In fact, most research indicates that during the twentieth century, that managed care has been a resource that has somewhat restrained the growth of health care costs by governing the delivery system (Morrissey, 1997). In the beginning, the beginning impression began in the western part of the United States to mimic the employee model plans similar to the Kaiser Permanente.

The Kaiser Permanente provides the opportunity for employment to doctors and any physicians and other supplementary medical staff directly. (Morrissey, 1997). As a result, of all the publicity of the managed care in the private sector of the world, allowed the public sector to embrace it in the public American economy. The enormous growth allowed for additional medical expenses for the senior citizens, which was fortified by the national administration to allow Medicare managed care choices during the 1970s and 80s (Milestone, 2008). Provider Contracting

During the time of the Presidency of the Clinton government, that is when the initial meetings were held to address the concerns of whom should be held liable for the healthcare plan. Over the years, this has been an ongoing topic to address throughout the years. As of 2011, this topic is still very controversial and a topic that is open for discussion on many different levels. The fact that in most cases the insurance company has the authority to make decisions concerning the medical well fair continues to be an open debate filled with controversy.

Whether or not it is the right for the insurance company to dictate the future of a member that is paying for his/her medical affairs will continue to be an open discussion. The insurance views this decision as their liability, whereas the member views the ultimate decision a dictator of his/her medical affairs. According to the Cigna Healthcare website, the final decision is usually in most cases dictated by the top medical professionals that have been appointed as the advisors and decision maker so to speak of the medical claims.

This decision is usually dictated through the utilization department. From personal experience working in a medical field in the psychiatric facility, there are many steps that are taken in efforts to get the member approved for additional days. For example, members may have additional days, if he/she falls under a certain criteria, based on behaviors, or the cognitive status. If the member does not meet the benchmark of criteria based qualifications, then the member has up to 48 hours to be discharged from the facility.

In some cases the member does not get a notice, it really just depends on the contract. This in itself, sounds inhuman, but it is supported and approved to be a part of the guidelines if the member signs and agrees to the stipulations. Cost Containment According to the insurance industry, the new experience of this sky rocketing deductible health insurance cost. Of course, this raises a lot of questions as to if the health insurance is getting better or declining.

According to Harris Interactive, he believes that based on current reports given; there are no signs that employees are allowing the high deductibles to discourage him/her from getting the coverage. Part of that of that decision could be based on employees no having any other options for medical care. Some insurance is always better than not having any at all. The fact that members are still applying for insurance is not the for sure indicator that members are pleased with his/her options available. (Lee, 2005).

Effects on Medicare and Medicaid The effect on Medicare and Medicaid has been an ongoing concern for over 20 years. For over 20 years efforts to encourage managed care models in Medicare and Medicaid has undergone several different experiences in the past. According to reports, Medicare and Medicaid have undergone extremely different experiences in the past, which has been audited by the employee enrollment, plan participation, and the achievement of reaching the targeted goals of public policy-makers.

The Medicare Modernization Act of 2003 introduced a major transformation to engage and retain private health plans (Lipman, 1994). The future role of government regulations, to include ERISA and HIPPA HIPAA primarily puts attention on preventing employees from being discriminated against when concerning medical insurance coverage, privacy on individual’s medical diagnosis, and allowing access to designated times when an individual can enroll when the person may have declined the coverage initially.

According to Kongstvedt, there are straightforward stipulations for a facility to be given rights to qualify for Medicare contract. The facility must have a license, which was issued by the facilities state in order the meet the regulatory authority that consists of Medicare Part A and B (2007). There are exceptions to the regulations, which gives a new facility will receive a waiver for the first three years (Kongstvedt, 2007).

Speaking from personal experience, having worked in a nursing home for 5 years, and one of the nursing homes that I initially began working at was a startup community, in which I had the privilege of learning this information and knowledge of the exception to the rule. The startup community did not have to be so concerned with the Medicare billing side until the facility was up and running, because of the exception stating that Medicare holds the facility in a 3-year contract waiving that responsibility of regulations.

The Employee Retirement Income Security Act (ERISA), approved in 1974, was implemented in efforts to help assure benefits would be given to the employee pension plans. The regulations according to the law, allow medical insurance plans provided by private business and unions. There are specific organizations that are exempt from the ERISA act such as, state, church, and local government plans. The ERISA necessitates that medical insurance plans that are supported by private employers allow for specific information assessable to any employees that are members under the insurance plans.

ERISA also necessitates that guidelines are set in place for employees with benefits to have access to making complaints and appeals if needed. Employees have 90 days to accept or decline claims and 60 to accept or decline appeals (Cordes, 1995). Conclusion In conclusion, there is not a lot of research that has been proven about other managed care plans, but HMOs having proven through research that it has saved money. Nevertheless, there is still critical discussion concerning the lack of services.

Managed care continues to grow and continues to have areas that need to be address to achieve total satisfaction from the member’s. While most plans has limitation or restrictions there still needs to be other options for members that do not live in prime locations. Recommendations Preparing for the future, citizens should assertively take the responsibility of researching ones on healthcare. It is important to have the knowledge of knowing that this responsibility will include researching the benefits that are presented to him/her in order to choose the right health care plan.

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