Question

What is managed care? How does healthcare get paid for in the US? From this chapter's discussion questions: Discuss the impact that managed care is likely to have on your career in healthcare? What are the various codes of ethics for healthcare professionals ?

Answer 1

The term managed care or managed healthcare is used in the United States to describe a group of activities intended to reduce the cost of providing for-profit health care and providing American health insurance while improving the quality of that care.

Costs of health care are higher in the United States than in other countries and put a strain on the overall economy. Health care is paid for by government programs (such as Medicare and Medicaid), private health insurance plans or employer-paid” health insurance(usually through employers), and the person's own funds (out-of-pocket).

One of the most characteristic forms of managed care is the use of a network of healthcare providers to provide care to enrollees. Such integrated delivery systems typically include one or more of the following:

• Designated doctors and healthcare facilities, known as a provider network, which enrollees are required or incentivized to use
• Formal utilization review and quality improvement programs including disease management and case management
• An emphasis on preventive care including wellness incentives and patient education

The techniques can be applied to both network-based benefit programs and benefit programs that are not based on a provider network or Insurance plan companies.

types

Managed Care Organisations manage financing, insurance, delivery, and payment for providing health care: Premiums are usually negotiated between MCOs and employers. MCOs function like an insurance company and assume risk. MCOs arrange to provide health care, mainly through contracts with providers.

• Health Maintenance Organizations (HMO) usually only pay for care within the network.
• Preferred Provider Organizations (PPO) usually pay more if you get care within the network
• Point of Service (POS) plans let you choose between an HMO or a PPO each time
• Exclusive Provider Organization (EPO)

Impact on nursing

• Managed Care Nurses serve as the liaison between patients, doctors, healthcare providers and Insurance companies.

• In contrast to direct patient care at the bedside, their role is to advocate for all patients enrolled in the healthcare delivery system.

• The overall goal of a Managed Care Nurse is patient advocacy.

• It gives opportunity for nurse to undertake tasks once reserved for doctors to registered nurses, and the direct care of patients to people who have less training.
• a model in which nurses can participate in all aspects of a patient''s care, rather than repeat a set of same tasks on a number of patients.
• Ensuring quality care for patients in a managed care setting is another important aspect of being a managed care nurse soimproved patient outcomes and satisfaction.

• work directly with patients of all types, including the young and old, who may need all different types of medical care, physicians, nurses, medical facilities, insurance companies, and government agencies.

• act as a liaison and educator, ensuring that patients receive high-quality health care when they need it.

• be responsible to advocate for treatment plans that are appropriate and cost-effective.

  There is certification course for managed care nurses. A managed care nursing career has a number of advantages over some other nursing careers. For instance, they can often work regular hours and a somewhat chaos-free work environment. However, more time spend on completing paperwork rather than directly caring for patients. Managed care nurses work in office settings rather than in clinical settings. They are often employed by clinics, hospitals, community health centers, and insurance companies. Some government agencies and social service programs may also hire managed care nurses.

Codes of ethics for healthcare professionals

• A code of ethics clarifies roles and responsibilities within a profession and provides guidance to the professional for addressing common ethical questions.A professional code of ethics is designed to ensure employees are behaving in a manner that is socially acceptable and respectful of one another. It establishes the rules for behavior and sends a message to every employee that universal compliance is expected.

• The Code of Ethics consists of two kinds of standards: Principles and Rules of Conduct. The Principles are broad standards of an aspirational and inspirational nature, and as such, express ideals of exemplary professional conduct.

• The Rules of Conduct are specific standards that prescribe the minimum level of conduct expected of each health care professional

• EXAMPLE

  NAHQ(National Association for health care quality ) Code of Ethics for Healthcare Quality Professionals and Code of Conduct