CA 3 - Managed Care

Running Head : Managed Care

Managed Care (Name (Institution (Name of Instructor (Course Subject

Managed Care

Its is almost a certainty that new approaches to managing cost quality , and access will be developed , some will fail , while others will succeed and lead to still more changes . Health care cost have risen at variable rates , and the shocking increases experienced in the early 1990s slowed in the mid-1990s but have begun to appear again at the turn of the 21st century (Kongstvedt , 2003 . Managed care has been effective in holding down the rate

of rise , but many of the fundamental reasons for increased health care cost remain today which include rapidly developing medical technology , drug therapy advances and rising prescription drug prices , shifting demographics , especially the aging of the population , high expectations for a long and healthy life , greater control of health care by consumers and associated demands upon the health care system , the litigiousness of our society which leads physicians to practice defensive medicine , high administrative cost related to the care that is delivered , inefficient or poor quality care rendered by some providers , high cost of compliance with government mandates , decreased levels of public dollars to pay for entitlement program health care , and lastly , cost shifting by providers to pay for health care rendered to patients who either cannot pay or are covered by systems that do not pay the full cost of care (Kongstvedt , 2003

While the term managed care can be defined in many ways and is constantly evolving to meet the demands of the health care market , the differentiating feature of managed care relative to FSS is the use of provider networks (McCarthy , 2004 . Defining the different types of managed care organizations (MCOs ) is an ever-evolving challenge . Ten to fifteen years ago , it was relatively easy to distinguish among different types of MCOs (Kongstvedt , 2003 . According to Kongstvedt , health maintenance organizations (HMOs , provider organizations (PPOs , and the more recent point-of service (POS ) health plans were the distinct types of organizations and were identified as such . MCOs are the predominant vehicles for the provision and payment of health care benefits , at least for the private sector , and more often , seemingly pure MCO will be a subsidiary of a larger health plan or insurance company that offers the other types of MCOs to the same market (Kongstvedt , 2003

The perceived success of HMOs and other types of managed care organizations in controlling the utilization and cost of health services prompted the development of managed care overlays that could be combined with the traditional indemnity insurance , service plan insurance , or indemnity like self insurance (Kongstvedt , 2007 . These managed care overlays are intended to provide cost control for insured plans while retaining the individual 's freedom of choice of provider and coverage for out-of-plan services . The types of management overlays include general utilization management , specialty utilization management disease management , catastrophic or large case management , and worker 's compensation utilization management

Typically , participating providers in PPOs agree to abide by utilization management...