1 / 16

Managed Care

Managed Care. Chapter 19 Dr. Tracey Lynn Koehlmoos. Defining Managed Care. Ill-defined, ill-applied and overused term. Patient utilization and provider practices are managed by an entity with a fiduciary interest in the interaction between the two. Back in the Old Days….

deon
Download Presentation

Managed Care

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript

  1. Managed Care Chapter 19 Dr. Tracey Lynn Koehlmoos HSCI 678 Intro to US Healthcare System

  2. Defining Managed Care • Ill-defined, ill-applied and overused term. • Patient utilization and provider practices are managed by an entity with a fiduciary interest in the interaction between the two.

  3. Back in the Old Days… • Access to care increased 1960’s • Employers and Federal Govt--payors • Consumer’s choice of provider, unrestricted • Provider’s choice of services, FFS • Managed care (pre-paid healthcare) served a small segment of US population

  4. Paul Ellwood:The Father of Managed Care

  5. Rise & Fall of Managed Care • HMO Act of 1973, Paul Ellwood • 1979 start of NCQA • 1980’s, Employers focus on wellness • 1996 HIPAA passed • By 1997, 8.1 million Americans in some form of managed care • 2000 HIPAA enacted • 2000 Death of Managed Care ?!?

  6. Individual patient Acute Care Overservice Incentive for providers Unrestricted access to providers by the patient Population Disease Prevention/ Health Maintenance Underservice Incentive for Providers Barriers to providers/ Controls and restrictions FFS vs. Managed Care

  7. Forces of Change • Sky-rocketing costs • Need to establish cost predictions • Societal need to account for expenditures • Optimal vs. maximal

  8. Do you know your ABC’s? Continuum of Managed Care Managed Indemnity Service Plans PPOs POS Open Panel HMO Closed Panel Increasing Cost and Quality Control

  9. Do you know your ABC’s? • Evaluate MCO’s based on: • Set up, Provider Payment, Enrollee Incentive • Cost Savings Mechanisms, Risk Assumption • Alphabet Soup of Managed Care: • HMO (staff model), HMO (group model) • IPA/Network, PPO, EPO • POS, PSO, • IDS (PHO, IPA, MSO)

  10. Managed Care Today • 92% of Employer Sponsored Insurance in Managed Care, 2002 • 60% of Medicaid • Medicare+Choice Plans on the decline • POS fastest growing model • Mergers, bigger MCO’s • 11 HMOs capture 50% of enrollees

  11. Managed Care Pros • 1990’s—slow of healthcare expenditures • < admissions, shorter LOS, < tests • Reliable Outcomes Measurements • Best Practice Guidelines • Reduce waste and redundancy • Promotes prevention and promotion • Chronic Disease Management

  12. Managed Care Cons • Phys/Hospitals working to protect economic interests • Failure to arrest US health expenditures • Physician economic survival v. patient health • Potential “under service” due to short LOS • Lack of accountability for public health quality • Lack of developed and useful IS • Altered core function of insurer

  13. Physician Controversy! • Gag Rules • Physician Autonomy • Physician Satisfaction

  14. Enrollees’ Discontent! • Consumer Choice • Selection Bias • Turnover • Consumer Satisfaction

  15. Quality and Regulation • Quality Research HMO = Indemnity • Should we leave MC to market forces? • Cost containment: Does MC work?

  16. Conclusion • Are the cost savings days over for good? • Is Managed Care Dead or just evolving?

More Related