Managed Care


Managed care refers to health care delivery system structured to control cost, quality and utilization. Managed care plan is a form of health insurance. Managed care has for the last 20 years dominated delivery of health care in the United States. Over 150 million health insurance arrangements participants in America fall under different managed care umbrella. The development demonstrates a trend from an association between insurer and care providers under fee-for-service traditional insurance arrangements to the present systems where in, insurers operate more closely with huge, group payers that include government agencies and primarily employers (Navarro& Cahill, n.d.). The Managed care term encompasses extensive kinds of arrangement, majority of which get on evolving as they change based on market pressure. Health plans in managed care system try to control and coordinate the utilization of the medical health care services by limiting services delivery. This paper review how managed care as a delivery technique has enhanced the health services transfer to outpatient as well as other nontraditional care setting and its impact on delivery, financing, and access of health care in the United States.

Analysis of Managed Care as a Delivery Method and how it has facilitated the Health Services Transfer to Outpatient and Other Nontraditional Care Settings

Managed care is a technique of the healthcare services delivery in a manner which puts limited resources to effective use in patient care optimization. The US federal government has provided Medicare and Medicaid insurance as a form of managed care programs to cater for its citizens. The Medicare provides coverage to individuals over 65 years and above, those that are disabled, as well as the needy via a state partnership arrangement via the Medicaid programs. The Medicare program has enhanced medical treatment for the beneficiaries by ensuring that 75% of their medical cost is covered.Principles of managed care are also the basis for effective pharmacy benefits administration. The 2003 Medicare Modernization Act included coverage for outpatient prescription drug for beneficiaries of Medicare via Part D establishment. Consequently, the vast Americans majority has some kind of pharmacy and medical benefits (Kerr& Davis, 2000). Pharmacy benefits, outpatient medical benefits, and in-patient hospital benefits are the three biggest cost cores for health plans. Outpatient and hospital medical services are normally managed under the medical benefits, while the pharmacy benefit is normally controlled separately.

Managed care organizations in a clinical environment offer health care services to the enrolled population. They therefore contain the ability to offer patient follow-up and monitor outcomes and treatments across an extensive range of significant clinical areas of research that include antibiotic use patterns and resistance, nosocomial infections control, and evaluation and investigation of new screening diagnostic and strategies methods. These abilities are specifically essential in control and monitoring of emerging infections.  Some states implements a number of initiatives to integrate and coordinate care above traditional managed care. These initiatives are centered on enhancing care of beneficiaries with complex and chronic conditions. This is enhanced by aligning the incentives of payment with development of accountability and performance goals for improved quality care (National Academy of Science, 2000).

Impact Managed Care on the Access, Financing, and Delivery of Health Care in the United States

The managed care rapid rise is perhaps the most renowned change which has taken place in the country. The rising stressed on quality and cost of services has initiated system shifts in health care payment and practices techniques. This changing setting poses challenges to the health care professionals’ traditional roles. Forces of private market and public policies have a high deal of influencingthe US health care. Both of these effects mold for whom, where, and how health care dollars are used. They as well play a duty in determining who can give health care services. Managed care has highly enhanced health care access in that it has reduced the cost of health care services for those who could not afford this care (Amonkar et al., 2000). Today the elderly, disabled, and the poor can easily access health care services without worrying much about the cost. They can easily go for medical checkup even for preventive measures without worries. Managed care has made it possible for elderly and individual suffering from chronic illnesses to access medical care at home, in nursing homes and in hospice at any time. It has also made it easy for the beneficiaries to get better outpatient services including prescribed drugs.

Managed care involved the provision of government Medicare and Medicaid insurance to the elderly, disabled, and financially disadvantaged individuals in the country. Medicaid managed care offers the Medicaid health benefits delivery as well as the delivery of extra services via contracted organizations between managed care organizations and Medicaid agencies which accept members’ monthly payment for these services. By contacting different forms of managed care organizations (MCOs) for Medicaid health care services program delivery to the enrolled individuals, state can lower costs of Medicaid program and improve the management of health services utilization. Enhancement of performance of health plan, health care outcomes and quality are main Medicaid managed care objectives (, 2017). The insurance pays about three-quarter of the medical charges for the beneficiaries and they only get to pay a quarter of the required amount. This reduce their medical cost a great deal and make their medical care affordable to them, especially since the covered individuals are highly likely to have persistent medical issues, which demand that they may seek health care services frequently. The insurance ensure that the beneficiaries are able to get the care they need without being financially exhausted. This plays a great deal in preventing premature death.

The managed care ensures effective delivery of care. It has promoted coverage of inpatient hospital care that includes the provision of regular nursing services, intensive care, X-rays, inpatient rehabilitation, laboratory test, inpatient prescription drugs, psychiatric hospital and long-term care among other things. It has also enhanced skilled nursing facility care, home health agency, and hospice care. The services are provided with high level of efficiency. Managed care has enhanced the quality of care given to the beneficiaries even to those in need of end-of-life care. The managed care has also dictated on various measures to ensure that physician ensures efficiency in their services (Hoffman,Klees& Curtis, 2000).

Managed Care’s Role in Promoting Health

Managed care plays a great role in promotion of health in the United States. Its main contribution involves ensuring that the elderly, disabled and those that are financially disadvantaged can access quality health care services. Managed care has historically been aimed at providing individuals access to cost-effective, high-quality health care via a delivery system which influences the services utilization, services accountability and cost of services. Although the previous managed care generation concentrated basically on minimizing hospitalcosts,today’s managed care generation also communicate and develop practice guideline for cost effective and effective care. They also build providers network to enhance the health care deliverycost-effectiveness, seek progressive improvement of quality, facilitates early treatment and preventive services access. In addition, they supportpatients as well as their families in establishing the most suitable available treatment. They also play the role of coordination among complex patient, and providers payers to promote continuity of care and communication (Kerr & Davis, 2000)

The managed care ensures that individuals with chronic illnesses and those that have high chances of experiencing medical financial burdens are covered. This prevent high rate of preventable premature death. The provision of managed care also ensures proper care is given to patients in hospice and elderly in the nursing homes. This therefore ensures that these enrolled in the managed care plan have received the quality and reliable care. Managed care also promoted preventive care. The current trend of health systems managed care opens the door to extra effective management of chronic diseases via preventive care (Amonkar et al., 2000). Managed care provides great chances for the public health improvement in the country. The health of the population can be enhanced by structured format managed care organizations employs on the health care services delivery that is better compared to fragmented manner in which health services provided in other contexts. Managed care organizations can as well offer databases for public health evaluation purposes and surveillance, so as to enhance the actual health care issues facing the nations.

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