Biology

Health Care System Evolution Paper

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Health Care System Evolution Paper: Managed Care

In the United States, the healthcare delivery has evolved and led to the formation of Managed care initiative. In early 20th century, the United States did not have public and private insurance. This led to the emergence of Managed Care .In this case, Managed Care refers to any kind of arrangement whereby such organizations as insurance company or HMO, which represent another kind of Doctor-Hospital network, act as the midpoint or intermediate between the physician and the person receiving care. Because of this, the influence of Managed Care on the current health care system has been tremendous. It has for instance spurred the creation of PPOs and HMOs.

The growth of the Managed Care was significant. Part of the reason for this was that the physicians as well as other providers of healthcare were charging more and more money for services that they were providing. This is because they were competing to control the (Rodwin, 2010). Another thing concerning these physicians is that they had a lot of conflict of interest as far as the need to sell their medical services in a bid to charge more and the need to do what was in the patient’s best medical interest. Managed Care has therefore, led to a lot of change in the way America handles the health care delivery system.

Currently, there are many times that a doctor is reimbursed or is paid for what is seen as medically necessary on the basis of the diagnosis of the patient and the normal way or course of treatment for the particular diagnosis. The doctors are also reimbursed at a rate that is pre-determined for specific types of visits. This has resulted in patients requiring pre-authorization or pre-certification from the insurance organizations for certain procedures and tests.

There was also the development of the Point of service insurance plans because of the managed care. According to the Point of Service insurance plans required the patients to be saving money by staying within a network of providers, which are specified. This type of insurance plan is still applicable today since a patient can save huge amounts of money by selecting a provider who is in-network. In case the patient selects an out-of-network provider, it means that he or she is running the risk of either being not covered at all or being under-covered for any procedures or tests performed or done while under the care of the provider. These insurance plans can reduce their costs and in turn also keep the costs of the consumers down by limiting or reducing the amount of services that the physician’s in-network offers.

Managed care also led to capitated care. Analysts have argued that this kind of care reduces the amount of services that a physician offers to a patient . In capitated care, the physician is paid at a rate for every patient who lists the physician as their main or primary care provider. This rate is fixed regardless of the number of times the physician see the patient. The physician in this case can get the incentive of selling the patient because he or she is the primary care provider. This plan will also give the physician less incentive if he or she sees the patient on regular basis. There is no evidence however, that capitated plans have any big effect on the financial incentive of the physician in increasing or reducing services to patients.

In the recent years, the effectiveness of Managed Care has begun to decrease. The cause of this is the rising costs of health care. Because of the increased cost, Managed Care has been forced to raise its charges for the clients including the premiums and particularly deductibles. In current or modern day age and day, patients have become better educated on their diagnosis as well as the course of treatment that should be used . This has also led to a problem in managed care since the patients now expect certain things to be covered. These are the things which they did not expect some years ago since they were in the dark as far as their treatment options are concerned .

Therefore, so that they can remain competitive in the health care delivery system market of today, Managed Care has had to reduce the number of restrictions they used to place on the care that the physicians provide. The physicians have been left with the option of whether they want to participate as well as how much they can participate. This arrangement puts a lot of pressure on the today’s managed care plans since they now cover less than less than what a physician may recommend as the fair treatment or less than what is seen as medically necessary.

In today’s market, consumers have to weigh the cost of health care against the cost of not getting the treatment options that are not most up-to-date caused by lack of insurance cover. Because of the amount of technological advances there is a constant shift in the balance of this decision. Currently, the common treatment recommended for operable lung cancer may include surgery, then a post-operative X-ray as well as a visit by a doctor. In five years from now however, the course of the same treatment and maintenance may changed significantly on the basis of new technology. Therefore, managed care will be forced to keep up with the changes that come along and adapt them accordingly. If they do not do this, they will turn to be totally obsolete and ineffective .

In conclusion, it is important to note that the origin if the Managed care was the idea of controlling the health care costs by cutting down or restricting the amount of services offered. Today, the idea is still effective especially for those trying to limit the amount spent in healthcare or those having secondary coverage through such avenues as Medicaid or Medicare or spouse. However, the consumers and physicians are turning to be more savvy and unwilling to accept what is offered by managed care plans alone. This implies that there will be fewer restrictions on the services provided. This will eventually phase out the Managed Care plans. At this point, there will be the need of finding a new way of controlling cost and managing the conflicting interests given to physicians every day.

Works Cited

Fang, H., & Rizzo, J. (2008). The changing effect of managed care on physician financial incentives. American Journal of Managed Care, 14(10), 653-660.

Fang, H., & Rizzo, J. (2009). Has the influence of managed care waned? Evidence from the market for physician services.. International Journal of Health Care Finance and Economics, 10(1), 85-103.

Rodwin, M. (2010). The metamorphosis of managed care: implications for health reform internationally. Journal of Law, Medicine and Ethics, 38(2), 352-364. doi:10.1111/j.1748-720x.2010.00494.x

� Rodwin, M. (2010). The metamorphosis of managed care: implications for health reform internationally. Journal of Law, Medicine and Ethics, 38(2), 352-364. doi:10.1111/j.1748-720x.2010.00494.x

� Fang, H., & Rizzo, J. (2008). The changing effect of managed care on physician financial incentives. American Journal of Managed Care, 14(10), 653-660.

� Fang, H., & Rizzo, J. (2009). Has the influence of managed care waned? Evidence from the market for physician services.. International Journal of Health Care Finance and Economics, 10(1), 85-103.

� Rodwin, M. (2010). The metamorphosis of managed care: implications for health reform internationally. Journal of Law, Medicine and Ethics, 38(2), 352-364. doi:10.1111/j.1748-720x.2010.00494.x

� Rodwin, M. (2010). The metamorphosis of managed care: implications for health reform internationally. Journal of Law, Medicine and Ethics, 38(2), 352-364. doi:10.1111/j.1748-720x.2010.00494.x

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