CONTENTS Executive Summary Background Definitions stakeholders Options and implications for managed care Individual practice association (IPA) or network model HMOs Staff or group model HMOs Point of service (POS) plans Medicare/ Medicaid Medical tourism
Potential Problems Possible Resolution and its Possible Effects Conclusion and Potential Areas for Further Study Recommendations
Executive Summary Healthcare Information Technology (HIT) has been shown to improve organizational efficiency and has the potential to transform healthcare and the managed care industry in the near future. The potential impact of HIT on cost savings and quality improvement has led Congress to enact the American Recovery and Re-investment Act of 2009 (ARRA) which encourages the use of information technology to achieve fully integrated electronic health records system in the United States. This law has a lot of implications for the managed care industry which is responsible for the healthcare of a large percentage of Americans. There are many models of managed care and there are also many models of Electronic Health Records (EHRs) which suit each of these different models. However, what is good for one model of HMO may not be good for the other and I hypothesize that this may create many independent, self-sufficient health information systems that may not allow the over-arching goal of the ARRA Act of interconnectivity and interoperability to be met. I propose that a generic model of health information system be developed by the ONCHIT which would have as its backbone, the Centre for Medicare and Medicaid (CMS). This system will be anchored around the Medicare and Medicaid programs and the managed care organizations would design their own systems in such a way as to be interconnected with this system, as opposed to having their own standalone systems. There are many teething problems within this developing area and my proposition may cause some more, but if the ONCHIT ensures that the innovative MCOs who have already installed their own systems are not penalized but encouraged and the spirit of competition is not dampened among vendors, the expected benefits of EHRs may soon be reaped by all, especially the enrollees of the various managed care organizations in the United States.
Background Despite the widespread use of information technology in many industries in the general US economy, the health sector in general and managed care organizations in particular have yet to put its potential power to good use. The benefits of the value of information technology and its potential for cost saving and improved quality and reduced costs in the long run are well documented (Hillestad 2005, Chen 2009). Despite this however, about 17% of U.S doctor‘s offices and 10% of hospitals have only basic electronic health records, which are by no means integrated and interoperable (Blumenthal 2009). These conditions necessitate that the manner of recording patients‘ clinical information in most care settings is in paper form, which means that the process of reimbursement and payment of claims by managed care organizations is in paper format without any way of truly monitoring care across the different variants of the managed care organization systems. This has many implications for quality control and measurement in the managed care settings of both public and private payment systems including Medicare and Medicaid (Hudson-Scholle 2010). In a bid to remedy the situation, the US government enacted the American Recovery and Re-investment Act of 2009 (ARRA) which contains legislation on the use of...