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Managed care

الكلية كلية التمريض     القسم قسم التمريض العام     المرحلة 4
أستاذ المادة سجاء هاشم محمد كاظم       6/26/2011 9:32:24 PM

Managed care What is “managed care”? l Managed care” was touted as a way for employers to “manage cost” l Attempt to reduce cost and shift risk of health expense from the company to the insurer l Company would pay set amount and insurer would assume all risk l Insurer would then “manage” the patient to reduce costs l When it works well, Medicaid managed care can provide a comprehensive approach to providing and paying for high-quality medically-necessary health care services - l from routine to emergency - l within a coordinated system - l in a cost-effective manner Assumptions with managed care l If you keep people healthy, you reduce costs l If you only give people what they need (as opposed to what they want), you can reduce costs l If you make providers and patients aware of costs, they will be more prudent in their use of services Techniques of managing care • Selective contracting with providers • Financial incentives for providers • Financial incentives for patients • Medical management/quality improvement techniques – “Gatekeepers” -Organizational culture – Precertification -Practice guidelines – Referral authorization -Provider profiling – Case management -Disease management – Demand management -Drug formularies Potential strengths of managed care • Containing the increase in health care costs • Improving quality – Creating more rational systems of care – Improving coordination of care – Enhancing communication among providers – Reducing variation in practice – Improving access – Promoting prevention and wellness • Enhancing accountability Potential concerns about managed care • Impaired continuity of care • Withholding of necessary care • Failure to provide “state of the art” care • Increased administrative costs • Reduced clinical autonomy • Hindering provider advocacy for patients • Promoting competition based on risk selection and not efficiency of providing care • Managed Care – Focus on supply-side (health care provider-side) of market rather than on the demand size. – Often patients face very little cost sharing (prices close to zero) – Quantity constraints (such as seeing a “gatekeeper” primary care physician before seeing a specialist). – Capitation based reimbursement– providers received fixed, lump sum per patient, regardless of actual utilization. – Only 15% of Medicare elderly choose managed care arrangements – A number of HMOs have backed out of providing service • Hospice and home health care – End-of-life expenditures are 27% of Medicare costs. May be less expensive to provide home health care rather than expensive in-patient procedures – Has not slowed the growth in Medicare costs managed care: is used to describe a variety of techniques intended to reduce the cost of providing health benefits and improve the quality of care ("managed care techniques") ...intended to reduce unnecessary health care costs through a variety of mechanisms, including: economic incentives for physicians and patients to select less costly forms of care; programs for reviewing the medical necessity of specific services; increased beneficiary cost sharing; controls on inpatient admissions and lengths of stay; the establishment of cost-sharing incentives for outpatient surgery; History: Managed care plans are widely credited with subduing medical cost inflation in the late 1980s by reducing unnecessary hospitalizations, forcing providers to discount their rates, and causing the health-care industry to become more efficient and competitive Managed care plans and strategies proliferated and quickly became nearly ubiquitous in the U.S. However, this rapid growth led to a consumer backlash. Because many managed care health plans are provided by for-profit companies, their cost-control efforts created widespread perception that they were more interested in saving money than providing health care. In a 2004 poll by the Kaiser Family Foundation, a majority of those polled said they believed that managed care decreased the time doctors spend with patients, made it harder for people who are sick to see specialists, and had failed to produce significant health care savings. These public perceptions have been fairly consistent in polling since 1997 Managed care techniques:One of the most characteristic forms of managed care is the use of a panel or network of health care providers to provide care to enrollees. Such integrated delivery systems typically include one or more of the following: A set of selected providers that furnish a comprehensive array of health care services to enrollees Explicit standards for selecting providers Formal utilization review and quality improvement programs An emphasis on preventive care Financial incentives to encourage enrollees to use care efficiently. Provider networks can be used to reduce costs by negotiating favorable fees from providers, selecting cost effective providers, and creating financial incentives for providers to practice more efficiently . A survey issued in 2009 by America s Health Insurance Plans found that patients going to out-of-network providers are sometimes charged extremely high fees. Other managed care techniques include disease management, case management, wellness incentives, patient education, utilization management and utilization review. These techniques can be applied to both network-based benefit programs and benefit programs that are not based on a provider network. The use of managed care techniques without a provider network is sometimes described as "managed indemnity." Types of network-based managed care programs There are several types of network-based managed care programs. These range from more restrictive to less restrictive, and include: Managed Care Managed Care is a term that is used to describe a health insurance plan or health care system that coordinates the provision, quality and cost of care for its enrolled members. In general, when you enroll in a managed care plan, you select a regular doctor, called a primary care practitioner (PCP), who will be responsible for coordinating your health care. Your PCP will refer you to specialists or other health care providers or procedures as necessary. It is usually required that select health care providers from the managed care plan s of professionals and hospitals serving residents in all age groups and various income levels. Managed care plans pay the health care providers directly, so enrollees do not have to pay out-of-pocket for covered services or submit claim forms for care received from the plan s network of doctors. However, managed care plans can require co-pays paid directly to the provider at the time of service. There are many different types of managed care plans. Most managed care plans offer health education classes or other programs to help enrollees stay healthy. Depending on the type of managed care plan join, there may be additional services, such as transportation, available . Benefits of Medicare • Approximately 40 million enrollees • Part A: Hospital insurance: covers 90 days of inpatient care per lifetime. • Part B: Supplementary medical insurance: pays for physician visits and services outside the hospital. optional, . • Part C: Medicare+Choice – optional, a managed care arrangement where elderly get certain additional benefits like prescription drug coverage and have restricted choice of providers Medicaid Managed Care Medicaid Managed Care offers many chance to choose a Medicaid health plan. Managed Care plans focus on preventive health care and provide enrollees with a medical home for themselves and their families. Use this web site to find out more about Medicaid managed care where you live.

 

المادة المعروضة اعلاه هي مدخل الى المحاضرة المرفوعة بواسطة استاذ(ة) المادة . وقد تبدو لك غير متكاملة . حيث يضع استاذ المادة في بعض الاحيان فقط الجزء الاول من المحاضرة من اجل الاطلاع على ما ستقوم بتحميله لاحقا . في نظام التعليم الالكتروني نوفر هذه الخدمة لكي نبقيك على اطلاع حول محتوى الملف الذي ستقوم بتحميله .