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Explore the characteristics of managed care, its impact on medical decision-making, and differences from traditional insurance. Learn about Managed Care Organizations (MCOs) and the Managed Care Organization Continuum. Understand the various care techniques employed in managed care.
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Managed Care • In the broadest terms, Kongstvedt (1997) describes managed care as a system of healthcare delivery that tries to manage the cost of healthcare, the quality of that healthcare and access to that care.
Characteristics of Managed Care • Managed care is a system that integrates the financing and delivery of appropriate medical care by means of: • Contracting selected MDs & hospitals to furnish comprehensive care • Setting a predetermined monthly, premium fee for services, • Incorporating financial incentives to encourage patients to use only resources in the plan. • Having physicians assume some financial risk for their work --thus the role changes from advocacy to allocation (gatekeeper), and • Monitoring health care providers for quality assurance and utilization management.
Characteristics of Managed Care Plans Versus Traditional Indemnity Insurance
Differences Between Managed Careand Fee-For-Service Coverage • The most important characteristic that distinguishes managed care from other forms of health insurance is the active influence on medical decision-making through: • Dissemination of clinical guidelines, • Pre-authorization programs for referrals, admissions, and diagnostic testing, • Creation of limited provider networks whose members agree to adhere to the practice standards developed by the plan.
Managed Care Organizations (MCOs) • MCOs are formal arrangements whereby distinct organizations are made responsible for managing a network of services and supports and are accountable for network performance. • These operational responsibilities are separate and distinct from the policy-level responsibilities of the public agency charged with governing the system. • As a rule, managed care organizations are responsible for keeping spending within established limits.
Managed Care Organization Continuum • Managed care plans are sometimes described as either loosely or tightly managed, indicating how much they actually manage the care of their members.
Managed Care Organization Continuum • A loosely managed program might allow a member to: • Receive specialty care without approval from his/her PCP, • Seek care from a physician who is not part of the plan’s network and have the care at least partially paid for by the plan benefit, • Obtain care at urgent care centers without preauthorization.
Managed Care Organization Continuum • A tightly managed program however, would require a member to: • Select a PCP from providers affiliated with the health plan, • Seek routine care from his/her PCP, • Seek prior authorization for urgent/emergent care that is not life threatening, • Request referral for specialty care services from his/her PCP.
Managed Care Continuum Use of Managed Care Techniques Less More Traditional Indemnity Health Plan Traditional with Cost Containment POS PPO HMO
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