Question

• Provide a thorough analysis of managed care, and discuss how it, as a delivery method, has facilitated the transfer of health services to outpatient and other nontraditional settings of care.
• Discuss the impact managed care has on the access, financing, and delivery of health care in the United States.
• Discuss managed care’s role in promoting health.

PLEASE USE SOMETHING THAT HAS NOT BEEN USED BEFORE!

Answer 1

MANAGED CARE

Managed care plans are a type of health insurance. They have contracts with health care providers and medical facilities to provide care for members at reduced costs. These providers make up the plan's network. How much of your care the plan will pay for depends on the network's rules.

Plans that restrict your choices usually cost you less. If you want a flexible plan, it will probably cost more.

There are three types of managed care plans:

• · Health Maintenance Organizations (HMO) usually only pay for care within the network. You choose a primary care doctor who coordinates most of your care.
• · Preferred Provider Organizations (PPO) usually pay more if you get care within the network. They still pay part of the cost if you go outside the network.
• · Point of Service (POS) plans let you choose between an HMO or a PPO each time you need care.
• Medical Savings Accounts (MSAs), dental plans, and vision packages.

Individuals and employers have many plans to choose from with each offering various types of organization, service selection, and costs. Generally, the more services required to fulfill various needs and wants, the more expensive the plan.

Health Maintenance Organization

The least expensive form of managed medical care is the Health Maintenance Organization (Kaiser). Upon joining an HMO, individuals pay a fixed monthly fee, called a premium. Generally an individual pays a small co-pay, perhaps $15.00 for each visit, and $10.00 for a prescription. The range of health services vary depending on the plan, so comparison of plans is of the utmost importance. A list of doctors and hospitals is provided and a primary care physician (PCP) can be chosen from that list. The PCP is responsible for the individual’s general health care and providing referrals to specialists if necessary.  

Preferred Provider Organization

A PPO is similar to a HMO in that an individual pays a fixed monthly fee, and co-payments upon visits; however, the individual has more choices in provider selection. Unlike the HMO the PPO doesn’t require a “gatekeeper” physician to see a specialist. Should an individual want care outside of their network, the PPO plan generally covers expenses, but at a smaller percentage. An out of network visit usually requires a deductible. Bottom line is that a PPO gives individuals more choice, which many view as better service, and as a result is the most expensive Managed Care plan. PPOs are also the most popular form of Managed Care (Health Insurance In-Depth).

Point Of Service

Point of Service (POS) medical care limits choice, but offers lower costs when compared to HMOs and PPOs. Generally an individual chooses a primary health care physician within a health care network. The physician becomes “point of service”. An individual’s primary health care physician can refer the individual outside of the network, but with limited cost coverage. Interestingly, POS requires that an individual do their own paperwork if seeking care outside of his/her network; individuals must fill out forms and keep track of receipts (Health Insurance In-Depth).

Medical Savings Account

Medical Savings Accounts are not common so the description of this medical care plan will be brief. Medical Savings Accounts (MSA) can only be offered by employers with 50 or less employees. The employee welfare policy must follow strict government guidelines. Tax deductible monies are deposited on a periodic basis in a MSA at costs lower then other programs. The trade-off for the lower cost of the program is a higher deductible should medical care be needed, perhaps for an emergency. Financial requirements apply as listed in government guidelines, as well. Deductible limits are $1,650 - $2,500 for an individual and $3,300 - $4,950 for a family. If an MSA sounds like it might be the right way to go, get more information at healthinsuranceindepth.com.

Dental Care

Dental care insurance is not the main focus, but is certainly worth mentioning. Individuals enrolled in Dental Insurance Plans pay a monthly premium for coverage. Generally the higher the dollar figure, the better the coverage. Sometimes an individual medical coverage may cover dental; however, this is not usually the case. There are two main types of dental plans. One is called the traditional care plan; the other is referred to as Managed Dental Care. Generally basic dental costs, such as visits and cleaning, are covered under both plans. Managed Dental Care works much like a PPO; individuals can choose a primary dentist (much like a primary physician) from a list of select locations only. Premiums are lower then traditional care, but choices are minimal (Health Insurance In-Depth). For more information see the web-links section for Dental Insurance carriers with descriptions that is attached to the document.

Vision Care

            Many vision service providers offer a managed care approach to vision care as opposed to the traditional fee-for-service plan. Group plans that can bring down costs significantly are affordable and beneficial to all. The goal for the employer is to find the best quality plan at a reasonable cost, with employee satisfaction as the number one priority. “With an employer paid managed care plan, the employer pays a set monthly rate per enrolled employee (including spouse or family). This allows an enrollee to receive, within the plan guidelines, an exam, frame, and lenses at no cost to them” (SVS).

Ways of transferring of Health Services

• The managed care, as a delivery method, has specifically facilitated the transfer of health services to outpatient as well as other nontraditional settings of care on the basis of a delivery system health care and influencing the utilization of services.
• It has also facilitated the transfer of health services towards outpatient, including other nontraditional settings of care with the help of developing and communicating practice guidelines for effective and cost-efficient care (Beik, 2014).
• In most of the situations, building networks of providers in order to improve the cost-effectiveness of health care delivery, and seeking continuous quality improvement are also some
• Ways of the managed care that facilitates access to preventive services and early treatment to the outpatient and other nontraditional settings of care.
• At the same time, managed care usually supports outpatients and their families in finding the most appropriate treatments available to the transfer of health services.
• Therefore, managed care transfers the health services and care through enhancing communication and continuity of care (Beik, 2014).
• Addition to this, when managed care maximizes resources and latest technologies, the transfer of the health services to outpatient and other can be possible effectively and efficiently.

IMPACT MANAGED CARE HAS ON THE ACCESS, FINANCING, AND DELIVERY OF HEALTH CARE IN THE UNITED STATES.

States are increasingly turning to Medicaid managed care as a key strategy to manage costs and encourage innovation in health care delivery.

Market forces are producing dramatic changes in health care financing and delivery mechanisms. Payment systems are rapidly moving away from fee for service to capitation and risk sharing between payers and providers.

These changes are likely to result in a major reconfiguration of the health care workforce over the next few decades.

In the world before managed care, individual physicians and hospitals were the system's principal billing units and workforce research focused primarily on physicians.

In the world after managed care, group practices and organized delivery systems are the principal billing units and physicians are one of a number of clinicians on a team of health care professionals. Application of managed care organization staffing ratios to the entire delivery system implies significant physician surpluses (particularly Shortages of nurse practitioners and physician assistants.

Successful development of the team delivery concept will require development of economic incentive systems that reward team effort. To stimulate thought about the challenges that a team concept produces, this paper presents an innovative model of team health production. Finally, the workforce modification suggests the need for an ambitious research agenda: one that deals with micro- and macro-issues of team and workforce composition, organizational forms and incentives, practice context, and overall health care policy.

The IOM definition emphasizes the integration of services and supports the team delivery of primary care. Primary care is the provision of integrated, accessible health care services by clinicians who are accountable for addressing a large majority of personal health care needs, developing a sustained partnership with patients, and practicing in the context of family and community.

Health care providers do not generally perceive Medicaid managed care as a catalyst for delivery system reform. Fragmented delivery systems, limits on the types of services for which managed care organizations are at risk, and the volatility in managed care markets all present challenges to improving care delivery. Policy and operational changes could enhance the role of Medicaid managed care in promoting patient-centered, coordinated, and high-quality care.

State policymakers are increasingly looking to Medicaid managed care as a key strategy to manage costs and encourage innovation in health care delivery.

Despite differences in local circumstances and state Medicaid programs, common themes emerged in conversations across the four communities.

For the most part, providers in the four communities regard health plans more as administrative entities than as innovators in delivery system reform. They do not perceive managed care organizations (MCOs) to be the primary sponsors of efforts to improve health care delivery for Medicaid beneficiaries, but report that some are involved to a certain extent.

Other community stakeholders have undertaken initiatives to improve care delivery, including activities to reduce use of hospital emergency departments (EDs), provide optimal care for patients after inpatient stays, coordinate physical and behavioral health services, and improve communication among providers. Grants or other special funding streams available for a limited time usually finance these activities. Respondents also note that community-based MCOs associated with safety-net providers tend to be more involved than other health plans in delivery system improvements.

Providers observed that managed care systems are designed to improve quality and control costs by encouraging competition among MCOs, but this may limit the extent to which competing plans participate in collaborative improvement efforts.

Based on providers’ perceptions, efforts on the part of MCOs to expand or enhance certain practices could be helpful in promoting the effective and efficient delivery of coordinated care.

• MCOs could contract with local trusted organizations or develop their own care management programs. Respondents emphasized that care managers making frequent, in-person contact with patients would be more effective than efforts to manage or coordinate care by telephone.
• Primary care providers say that plans could encourage appropriate use of EDs or better posthospital transitions by providing encounter data about hospital visits to them on a timely basis.
• Primary care providers and referral specialists say they need accurate and current lists of network specialists who will accept referrals.
• MCOs could consider ways to reimburse services such as group or home visits, which safety-net providers cited as being particularly helpful for patients with complex conditions.
• Reimbursement for more types of nonphysician professionals, such as patient navigators, and payment for appropriate supportive services, such as child care, transportation, or interpreters for medical appointments, could promote patient-centered care.

Certain policy or operational changes on the part of states could promote patient-centered care in Medicaid managed care programs and improve population health.

• To minimize market volatility, states could require that MCOs make long-term commitments to the program, discourage plan withdrawals by excluding reentry for a period of time, and minimize rounds of competition for new contracts.
• To minimize disruption in care associated with market volatility, states could consider current provider relationships in making plan assignments and require that new plans honor prior authorizations and provider relationships for ongoing care.
• To promote collaborative community efforts, states could develop new performance measures or pay-for-performance programs that credit MCOs for working with other community stakeholders to achieve improvements in service delivery for Medicaid beneficiaries.
• To encourage plans to compete on the basis of quality and to help enrollees and providers differentiate among plans, states could make easily understood, comparative information about MCOs publicly available on a timely basis.

The use of managed care is not the only approach to achieving high performance in the delivery of Medicaid services. Yet, activity and interest in Medicaid managed care are high and likely to increase with the expansion of Medicaid to cover more low-income adults in many states under the Affordable Care Act.

Therefore, certain policy and operational changes, as well as ongoing program monitoring and evaluation, are recommended to promote patient-centered, coordinated care.

IMPACT ON FINANCE

Economists believe to know better. Both economic theory and a considerable body of empirical research suggests that the bulk, if not all, of the fringe benefits bestowed by employers on their employees are paid for through reduction in the employees' own take-home pay. Thus, most economists would argue that whatever cost savings the managed care industry wrought from the providers of health care flowed through to employees in the form of added take-home pay or added jobs.

Poor people on Medicaid also should thank the managed care industry for a new-found dignity accorded these patients. In the 1980s, the fees private insurers paid doctors and hospitals for health care were so enormously high that many providers simply refused to treat Medicaid patients at that program's low fees.

In the economist's jargon, the physicians' and hospitals' economic opportunity costs of treating Medicaid patients were too high. In the meantime, the fees paid under managed care have been depressed to the point at which Medicaid patients look downright attractive by comparison. By depressing the fees paid for private patients, the managed-care industry actually has vested Medicaid patients with a new dignity in the eyes of doctors and hospitals. It is a major achievement that has gone almost unnoticed.

Aspects of Medicaid managed care that may affect access to and quality of care

Under managed care, the state pays a managed care plan a capitation rate—a fixed dollar amount per member per month—to cover a defined set of services for each person enrolled in the plan. In turn, the plan pays providers for all of the Medicaid services an enrollee may require that are included in the plan’s contract with the state. MCOs are at financial risk if spending on services and administration exceeds payments; conversely, they are permitted to retain any portion of payments not expended for covered services and other contractually required activities.

Managed care encourages providers to keep enrollees healthy in order to keep costs within the capitation rate, through preventive and appropriate care to avoid expensive hospital stays and emergency department visits. Capitation also provides more certainty when budgeting and encourages the efficient use of services.

Others argue that a capitated payment system that pays MCOs a set amount per enrollee and not on how much treatment is provided may create incentives to undertreat patients to minimize treatment costs. Capitated plans may also seek to enroll as many healthy patients as possible and discourage participation of disabled or high utilizing enrollees.

Incentives may also be influenced by capitation payment rates. For example, adequate payments should be able to provide access to coordinated and effective care while generating savings that can support additional medically necessary services. On the other hand, if capitation rates are set too low, they may create incentives to restrict services through use of gatekeepers, preauthorization policies, or limits on benefits.

Low rates may also motivate plans to pay less for services, which in turn may reduce the number of providers willing to treat enrollees thus impeding their access to care. In Illinois, for example, much of the traditional safety-net provider community boycotted the state’s managed care initiative when it was implemented, arguing that the payment rates were too low and the bureaucratic micromanagement was too high .

Network composition. FFS Medicaid programs typically contract with any qualified provider willing to accept Medicaid payment rates, and Medicaid beneficiaries who receive services through FFS are entitled to freedom of choice among Medicaid providers. Managed care plans can establish their own provider network qualifications, contract terms, and payment rates (within parameters required by the terms of the contract with the state). They generally limit MCO enrollees to a network of providers. MCO provider networks must be sufficient to provide adequate access to all covered services, taking into account the number, type, and geographic distribution of providers, among other factors, but there are no universal metrics to determine sufficiency.

Covered benefits. Contracts between the state and MCOs identify which state plan services are the responsibility of the MCO, which (if any) remain covered by the state, and which (if any) are provided by other vendors or through other delivery systems.

Contracting specifications and oversight. Medicaid managed care plans are required to meet access and quality standards that do not apply to other Medicaid delivery systems.

THE RELATIONSHIP BETWEEN MANAGED CARE AND PREVENTION

The rapid, extensive changes in the health-care system in the United States provide public health agencies with new opportunities for prevention-oriented relationships with the private health-care system

HMOs can play a powerful role in prevention for at least three reasons.

First, HMOs are rapidly becoming a major source of health care for the beneficiaries both of employer-funded care and of the publicly funded programs, Medicaid and Medicare.

This increase in managed care has been greatest in health insurance funded by employers.State governments also are converting to managed care for their Medicaid programs, which provide care to the poor and disabled .States have been particularly concerned about Medicaid beneficiaries' lack of access to primary-care providers and their overreliance on emergency room care, which lacks continuity .

Many HMOs use internal performance-measurement and quality-improvement systems such as Continuous Quality Improvement (CQI) to monitor, correct, and enhance their services. External systems of measurement and improvement are also imposed on the HMOs

Second, HMOs historically have included prevention, and they maintain and continue to develop systems to measure performance and improve quality of services, including preventive services.

Third, HMOs represent organized care systems that take responsibility for defined populations and are accountable to purchasers, individual consumers, and federal and state regulatory agencies for desired outcomes, including prevention outcomes.

WORKING GROUP'S RECOMMENDATIONS FOR CDC AND MANAGED CARE

As the nation's prevention agency, CDC is uniquely positioned to facilitate prevention practices through and with MCOs and can build on its established relationship with MCOs..

Summary of Assumptions, Opportunities, and Barriers Related to Managed Care and the Public's Health

Assumptions

• · The health system in the United States will remain dynamic, with continuing corporate mergers and evolution in the system's organizations and their roles.
• · Managed care will continue to grow rapidly as a source of care for Americans insured by Medicaid, Medicare, and employers. This growth will result in increased privatization of care for the poor and underserved.
• · Managed care has provided leadership in the integration of health-care services, and increased integration can potentially increase the continuity of care.
• · Because HMOs offer the capacity to both characterize and influence the services delivered to and the health status of enrolled populations, these HMOs are held accountable by purchasers, consumers, and regulators for delivering services and improving health status. This accountability is an inherent advantage of managed care.
• · Health-care purchasers, particularly large employers, have collaborated with HMOs to develop external systems to measure the quality of both preventive and treatment services in managed care and to hold HMOs accountable for their delivery. Purchasers are likely to continue to be leaders in this area.
• · The problem of the uninsured remains and may be increasing. The responsibility for caring for the uninsured rests with local government agencies, such as health departments and public hospitals.
• · Access to needed preventive services depends on more than insurance; it also depends on provision of enabling services, such as transportation and reduction of language barriers.
• · Staff of public health agencies need more practical knowledge about managed care and how it works.
• · In a highly competitive health-care market, performance measurement will be important to assure that the MCOs' need to contain costs does not displace quality of care as a priority.
• · Many state-level public health agencies have dual roles with HMOs, as both partners and regulators; these roles may be in conflict.
• · Partnerships between MCOs and public health agencies will be particularly valuable at the local level, where health promotion and health care are delivered.
• · The greatest potential for improving the health status of populations results from community-based action (e.g., reduction of risk behaviors such as tobacco use).
• · Because of their clinical orientation, MCOs are more likely to be active participants in the delivery of clinical preventive services than in the delivery of nonclinical preventive services. However, MCOs can be powerful partners in nonclinical preventive service areas (e.g., education, laws, and regulations to prevent the initiation of tobacco use and to ensure environmental intervention for children with high blood-lead levels).
• · MCOs have found that maintaining the health of their populations is an important way to improve their cost effectiveness.
• · As MCOs have become the primary provider of health care to large segments of a community, they have become more involved with the health of the community as a whole.
• · Many preventive services, even though they may be highly cost effective and may contribute to the quality of life, cost more to implement than they save. Therefore, particularly in capitated systems, additional incentives that favor investments in prevention are needed (e.g., performance measures that are prevention oriented).
• · CDC has a leadership role to play in building partnerships among MCOs, purchasers, and public health agencies at all levels.

Vision

• CDC's existing vision statement, "Healthy people in a healthy world through prevention," needs no modification. The challenge to public health agencies is to work with MCOs, providers, purchasers, and consumers to make this vision a reality.
• Recommended High Priority Activities for CDC
• Prevention Effectiveness and Guidelines
• Work with MCOs, purchasers, and state and local health departments in key areas of prevention effectiveness, including
• · using information to determine the prevalence, incidence, and burden of disease, and the availability, efficacy, acceptability, effectiveness, and cost-effectiveness of interventions to specify highest-priority health problems for prevention;
• · assessing, through original research or review of the scientific literature, the effectiveness and cost-effectiveness of population-based and clinical strategies for prevention; and
• · developing, disseminating, and evaluating a "Guide to Community Preventive Health Services," science-based recommendations for choosing and implementing community-based preventive services.

Medicaid and Managed Care

CDC will collaborate with states, MCOs, and HCFA to design and implement Medicaid managed care arrangements that specify cost-effective preventive services for Medicaid populations and hold all managed care plans accountable for the delivery of these services. Examples of activities include

· developing models to allow state Medicaid agencies to contract with MCOs for highest-priority preventive services and to specify essential services that occur outside the clinical environment to protect the public (e.g., tracing contacts of persons with communicable diseases) and

· developing priority -- including primary -- prevention indicators for use in monitoring the performance of managed care plans.

Research

• As several populations in the United States, including the Medicaid population, convert to managed care, CDC will undertake research to document the health effects of the reorganized systems that deliver preventive services. Examples of research topics include
• · comparing the site and quality of treatment of sexually transmitted diseases (STD) in a state where STD treatment was included in the Medicaid capitation with those in a state where funding was maintained for STD treatment in public clinics,
• · assessing the adequacy of follow-up for Medicaid-eligible children with elevated blood-lead levels, before and after implementation of Medicaid managed care, and
• · assessing the quality of occupational health services provided by MCOs.

Capacity Development in Public Health Agencies

As underserved populations are enrolled in managed care, bring MCOs and public health agencies together on common issues and help to refine the role of public health agencies.

Examples include

· preventing pregnancy among adolescents in a community, jointly assigning responsibilities for clinical and community-based activities among MCOs, the school system, voluntary organizations, and the health department;

· developing community-wide strategies to increase bicycle helmet use; and

· developing community-wide registries to facilitate childhood immunization.

· Enhance and develop capabilities within health departments and CDC inprevention-related areas critical to partnership with and regulation of MCOs. Examples include community needs assessment, coalition-building, quality assurance, utilization management, and health services research and evaluation.

Recommended Priority Activities for CDC

Information Systems

• Collaborate with MCOs and state and local health departments to standardize and improve their information systems so that these systems can be used for community-wide health assessment and surveillance of notifiable conditions, health determinants, and risk factors. Examples include
• · modifying a state's Behavioral Risk Factor Surveillance System so that, in addition to providing population-wide data on HIV risk and prevention behaviors, it provides information to individual HMOs on their member populations;
• using MCO infectious disease laboratory data systems for notifiable disease surveillance for the MCO population; and
• developing model public health surveillance and information systems that utilize electronic consumer records and insurance billing information.

Quality Assurance

• Assist in developing measures and other systems to monitor and ensure the quality of preventive services delivered by all providers. Examples include
• · working with employers on prevention requirements in contracts with HMOs and
• · working with the National Committee for Quality Assurance

Partnerships

• Continue to build partnerships and mutual understanding among CDC, public health departments, MCOs, and purchasers through activities such as
• · staff exchanges, including assignment of epidemiologists to HMOs;
• · mutual representation at conferences of public health interest;
• · technical assistance in areas such as immunization registries;

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