Managed Care Insurance Plans
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Managed Care Plans
Managed care plan is an insurance plan aimed at providing the insured healthcare services at a reduced cost through contacted health practitioners and facilities. The system ensures that values, utility and quality of services delivered by the system are contained as well as managed (Kongstvedt, 2009). The payments for the services of members are pre-determined, and the charge is set which is then paid per month as a capacitation. This program on one hand can be beneficial to agencies in reducing cost expenditure on healthcare and the management of utilization of healthcare services offered. Since the payments are done on the services provided, the contracted will often make an effort to improve the care delivery to boost their network.
In managed care, a person would have a selected care provider to coordinate the episodes of care and who handles referral to another specialist as per the client’s condition. In this plan, a person would select a preferred practitioner or care facility (Kongstvedt, 2009). In United States, several managed care organizations exist in different states serving people from all lifestyles and occupations irrespectively. The health providers are directly paid under the plan, and there is no processing of payments to be undertaken or out of the pocket settlement. The different types of managed care plans offer variety of care services ranging from health education, promotion, the actual treatment with referrals whenever necessary and transportation inclusive.
Managed care option focuses on providing the best quality of care at the lowest cost-minimizing wastage and expenditure healthcare services. This type of plan presents how rapid healthcare system of the USA has changed in the past and expressed the pressure within systems. The system provides an organized way to the provision of services and the compensation for the services offered (Kongstvedt, 2009). The costs of the episodes and expenditures are managed in a way that unnecessary usage is reduced.
Managed care plans fall into three categories, the health management organization, preferred provider organization and point of service. The managed care plan differs from other insurance plans based on the choice of the supplier and compensations (Kongstvedt, 2009). An agreement is conducted in prior with some specific providers and healthcare organizations to provide services to those enrolled in the plan at a reduced cost.
Health Management Organizations provide their services on prepaid basis, which is done as a fixed fee each month irrespective of the level of care needed within the month. The organizations provide a broad range of medical services to their clients ranging from consultations, hospitalization, and surgeries. All the services are provided by the care facilities within the network, and any other attention is only recommended and referred by the primary physician. A primary physician is the first contact for all care services for each and provides all the general care and recommend any referral to a specialist. This control of care translates to the control of the rapid increase in cost, unlike other insurance plans.
The second category is the Preferred Provider Organization. PPO is part of a particular network that provides services at a discounted rate sponsored by an insurance company, an employer or organization. Typically, the persons under this type of care are policyholders, employees or members of the group who receive services at discounted rates. Services are paid for as per the scenarios of care and the sponsors create incentives for use of facilities within the network. The sponsors of care reimburse directly to the service provider the exact amount. The doctor and the provider engage in negotiations on the services provided and the beneficiary only moves to seek for the service and pay for any charges based on co-payment.
Finally, the Point of Service plan is another category that combines the first two categories. A person would have a primary practitioner within and a deductible payable outside the network. Each time a person needs care, it can be sought as either a PPO or HMO. The primary doctor does the general care, and all the cost within the network is settled, and if one goes outside the system, only a part of the expenses are settled (Kongstvedt, 2009). However, if the primary practitioner makes a referral, the sponsor will still cover the costs. In HMO, there is only a minimal co-payment whereas, in PPO and POS, there is a situation of co-insurance where the service seeker pays a proportion of the cost of care.
Accountable Care Organization
Healthcare providers and facilities come together in a network to provide for and coordinate high-quality healthcare services voluntarily. This system ensures the appropriate care needed is received promptly making effort to eliminate duplication of services and prevent any medical errors. Several ACO programs can be offered and coordinated together to ensure improved service delivery to the beneficiaries (Pollack, 2011).
An ACO is formed around systems of care and provider organizations as many other institutions and care delivery systems transition into ACO or have systems that evolve it into an ACO. The team comes to beneficiaries as an advantage of improved care and the structures, and the infrastructures are adjusted to meet the recommendations of an ACO (Pollack, 2011). The Affordable Care Act of the United States has significant contribution to the accountable care organizations boosting care delivery. The medical institutions under the plan receive a share of the amount saved in episodes of care and on improved quality, which reduces duplication of the provision of services. Healthcare institutions and care providers need to become an accountable care organization to be admitted to share savings benefit in any state in the USA.
Providing accountable care is the focus of the American states and federal government, and this can be achieved by structuring facilities to fit the program and systems intended. States like Ohio are taking initiatives of improving efficiency in healthcare using different programs. The ACO's are being established because of the enactment of the Affordable Care Act by public and private payers. There is a feeling that every service provider be accountable for the quality and cost of the services delivered for the patient care (Pollack, 2011). ACO’s are paid through the fee for service program, and incentives are created for providers for keeping costs low while maintaining higher quality standards. The organizations receive universal payments for the service to the population they handle depending on the number of people in their catchments.
The payments are in three compartments, 50% constituting the fee-for-service 20% for care management while 30% is forming performance incentives for the desired standards of service (Pollack, 2011). The service providers handle managing utilization rates, the availability, and the quality of the services they deliver. They tend to achieve more in performing such tasks than racing for higher gains that in the end may make them suffer loss (Pollack, 2011). Managed care organizations can easily fit being accountable care organizations simply by embracing the structures in place of being an ACO and providing responsible services to consumers. They form networks for offering healthcare services to people at a controlled cost and maintained quality in a particular population of not less than five thousand people.