Managed Care Delivery Systems

Managed Care Delivery Systems Introduction: According to Terence Shea in an article published by HR Magazine (2005), in the last fifty years, employers' health cost have soared as coverage has expanded and medical care has been revolutionized. Since the early 1980s, there have been a number of governmental and corporate attempts to slow this dramatic rise in health care expenditures. Most health plans in the U.S. today involve some form of managed care. Nearly 90 percent of Americans with health insurance are covered by HMOs and other managed-care plans. The reason for the shift from the traditional to managed care plans was to hold down healthcare costs. As HMOs grew physicians in private or small group practices have become
An IPA is a legal entity organized and directed by physicians in private practice to negotiate contracts with insurance companies on their behalf. Participating physicians are usually paid on a capitated or modified fee-for-service basis. An IPA can exert influence on be half of its members to counterbalance the leverage of health care insurers. An IPA organizes the delivery of care, negotiates contracts with insurance companies; credentials and inspects member physicians, establishes primary care provider and specialist responsibilities; and disburses payment to
According to an essay published online by the United States Department of Health and Human Services, one of the goals of managed care HMOs contracting with IPAs is to prevent the potential overuse of health care specialists. The traditional HMOs permit access to specialists only with authorization from a primary care provider acting as a gatekeeper. According to a recent study, individuals who have direct access to specialists in their HMOs do not make more visits to specialist than individuals enrolled in gatekeeper HMOs. According to this essay, the rules governing the gatekeeper's role in an HMO may actually encourage additional visits to the primary care physician and to specialists. The rational is simple: the more visits one has to a primary care physician, the more opportunities one has to get a referral to a specialist. Thus, the Managed Care IPA model actually strain rather reduce the strain on both primary care services and the visits made to specialists (Health Care Costs and Financing, 2000). 3. According to an essay published online by the National Cancer Institute, transitional care can be defined as that which is required to facilitate a shift from one stage of care to another. For example, as a disease progresses, a patient may require vastly different levels of treatment within increasingly specialized, costly and comprehensive forms of treatment. For an increasing numbers of patients enrolled in HMOs with a goal of showing a profit,