Managed Care
Throughout the 1980s, insured individuals had a personal preference as to which providers they would utilize in health care, and with little to no resistance, insurance payers paid providers on a fee for service basis. With an increasing number of employers providing health insurance to employees, managed care started to rise in popularity to provide opportunities for previously negotiated fees and costs associated with groups of practitioners and hospitals to be a way to decrease overall health care expenditures. This method of insurance coverage decreased the ability for the individual to choose which providers they were able to receive care from and pay the least out of pocket. By visiting a practitioner outside of the managed care group, an increasing amount of expense was generated for the individual seeking care (Fuchs, 2013). While there was the backlash from the patient population, the overall good managed care was able to provide long term was in decreasing the overall expenditure for health care that was rising at an alarming rate, faster than inflation and rate of economic growth (Nunez & Kleiner, 2012). Increases in cost can be attributed to many advancements throughout medical technology with new treatments and diagnostics, transitions of hospitals into major medical centers, as well as the changes to the patient populations, including longer life expectancy (Nunez & Kleiner, 2012). Ultimately, the need for insurance changes was necessary not just from an economical standpoint but also from a level of care perspective. Desiring the cost efficiency, as well as patient-centered quality care delivery, laws were passed that helped to provide options for patients allowing them to choose the level of insurance controls concerning providers they chose to utilize, thus the emergence of HMO and PPO options (Shi & Singh, 2019).
Before the integration of managed care, many physician practices were private and did not have an association with a larger group or organization, this method of practice produced problems when care was transitioned to other practitioners and decreased care coordination (Alvarnas, 2018). Throughout the growth of managed care areas of monitoring were introduced to ensure the greatest cost savings, but also the maintenance of quality care. These changes required increased data transfer for evaluations of whether treatments provided were medically necessary if they were financially conservative without decreasing standards of care and staying apprised of patient health response due to treatment (Shi & Singh, 2019). All of these monitoring methods created a shift in the health care delivery system by required increased communication and inhibited practices and providers from operating in the previously siloed systems (Krol et al., 2015).
The United States health care system now has well-established managed care as the primary method of health care delivery throughout the country (Shi & Singh, 2019). Many iterations have been made over the years, and with Medicare and the Affordable Care Act, changes for quality improvement and increased communication were required (Alvarnas, 2018). As new economic forecasts are assessed, and cost containment for medical care is addressed, government changes in policy continue to be discussed. The governmental drivers of Medicare and the Affordable Care Act continue to drive forward the necessity of continuous quality improvement (CQI) throughout the health care delivery system. Hospitals, being one of the largest employers of health care professionals and providing health care to entire communities have become integral in the process of advancement and improvement of processes and procedures, and best practices in care. Quality indicators for a hospital can be determined based on the department, but also address overall function. When operating with the focus of CQI, constant evaluation and modifications are expected to address better the health needs of the communities served. Data sets are analyzed from each distinct area of a hospital and help provide insight as to the general quality of care perceived by patients, satisfaction level, and overall health outcomes. This information is highly valuable in the health care delivery system today as new medical technology continues to flood the markets. CQI offers an opportunity for the evaluation of new technology and assessment of data to help determine the best method of care and measurable outcomes to give actionable methodologies in improving care (Alvarnas, 2018). Philippians 1:6 states, “and I am sure of this that he who began a good work in you will bring it to completion at the day of Jesus Christ” (English Standard Version Bible, 2001). Continuing to focus in the direction of constant improvement throughout the field of health care will ultimately provide great works, processes, and better overall health of our nation.
The health care delivery system has drastically evolved over the years and continues to change. With most Americans covered by insurance, placing services within the managed care system, cost, and quality of care remain the primary drivers when addressing change (Shi & Singh, 2019). Looking into the future of health care delivery, quality care at a value level of expense takes precedence over the volume of care provided. There is great potential that the success of ACOs having provided quality care at affordable cost, utilization across all avenues of payers will be the preferred method of care (Shi & Singh, 2019).
References
Alvarnas, J. (2018). Why the future never arrives. The American Journal of Managed Care, 24(13 Spec No.), SP524.
English Standard Version Bible. (2001). ESV Online. https://esv.literalword.com/
Fuchs, V. R. (2013). The gross domestic product and health care spending. N Engl J Med, 369(2), 107-109.
Krol, M. W., De Boer, D., Sixma, H., Van der Hoek, L., Rademakers, Jany J. D. J. M, & Delnoij, D. M. (2015). Patient experiences of inpatient hospital care: A department matter and a hospital matter. International Journal for Quality in Health Care, 27(1), 17-25. doi:10.1093/intqhc/mzu090
Nunez, R., & Kleiner, B. H. (2012). Development of managed healthcare in the united states: Lessons for managers. International Journal of Management, 29(3), 29-35. Retrieved from http://ezproxy.liberty.edu/login?qurl=https%3A%2F%2Fsearch.proquest.com%2Fdocview%2F1040874442%3Faccountid%3D12085
Shi, L. & Singh, D. A., (2019). Essentials of the U.S. health care system. (5th ed.). Jones & Bartlett Learning, LLC.
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