managed care

Running Head Managed Care

Managed Care Managed Care

The role managed care within the health care delivery system is an important one , whether assessed in terms of in or out patient care , of hospital or community care settings . The importance of the professional nurse within the healthcare call system is acknowledged and supported throughout much of America . Decades of health services research have established the incontrovertible truth that health insurance is crucial in assuring adequate access to high quality , affordable care . Recent years , healthcare industry pays a special attention to

healthcare call centres and quality of the services provided by medical professionals

Managed Care Today

The main forms of managed care are Health Maintenance Organization Provider Organization , Point of Service . The aim of the managed care is to support healthcare industry and provide patients with quality medical services . Such regulation could force plans to shift from proactive to defensive care management , in effect authorizing everything instead of systematically reviewing utilization patterns and seeking continually to improve care management protocols and practices Rather than benefiting consumers , such regulation would make the long-term goal of universal coverage more elusive by adding to the per capita cost of care . Indeed , the threat of malpractice litigation has for many years forced physicians to practice defensively , prescribing tests and treatments regardless of clinical value (Kongstverdt 2003a With the cost of defensive medicine already estimated to inflate the nation 's health care bills by as much as 10 annually , the multibillion dollar price tag associated with defensive medicine raises serious doubts about whether proposals to expose health plans to essentially unlimited liability meet the shorthand test of balanced regulation promoting accountability without stifling progress (Intellimed Corporation 2007 . Following Lens (2002 : the fee-for-service system that preceded managed care was not without its faults . managed care has raised the "corporatization " of health care to new and unprecedented heights (57

Main Requirements and Procedures

Regulatory requirements regarding a health plan 's organizational structure and management fall into three main categories . Some are intended to assure clear accountability for plan policies by identifiable individuals . Others call for the involvement of individuals with appropriate expertise and experience in specific decision-making areas (for example , nurses involvement in development of practice guidelines . Still others exclude from health plan management individuals deemed to have conflicts of interest , or for other specified reasons (Brann and Mattson 2002

Health plans must comply with extensive reporting requirements - particularly in the areas of solvency and quality assurance - and provide reasonable access to plan records to permit verification of reported information (Cousineau and Nascimento , 2005 . In some cases this information supports activities to verify compliance with applicable standards in other cases it is used as the basis for consumer information . Reinke (2007 ) admits that

while federal agencies , policy makers , and provider organizations are promoting the electronic health record as a magic solution for many of the country 's health care system problems , some health plans are taking a scaled down approach and implementing a different health record to...