The term managed care is used to describe a variety of techniques intended to reduce the cost of providing health benefits and improve the quality of care ("managed care techniques") for organizations that use those techniques or provide them as services to other organizations ("managed care organization or MCO"), or to describe systems of financing and delivering health care to enrollees organized around managed care techniques and concepts ("managed care delivery systems"). According to the United States National Library of Medicine, the term "managed care" encompasses programs:
...intended to reduce unnecessary health care costs through a variety of mechanisms, including: economic incentives for physicians and patients to select less costly forms of care; programs for reviewing the medical necessity of specific services; increased beneficiary cost sharing; controls on inpatient admissions and lengths of stay; the establishment of cost-sharing incentives for outpatient surgery; selective contracting with health care providers; and the intensive management of high-cost health care cases. The programs may be provided in a variety of settings, such as Health Maintenance Organizations and Preferred Provider Organizations.
The growth of managed care in the U.S. was spurred by the enactment of the Health Maintenance Organization Act of 1973. While managed care techniques were pioneered by health maintenance organizations, they are now used by a variety of private health benefit programs. Managed care is now nearly ubiquitous in the U.S, but has attracted controversy because it has largely failed in the overall goal of controlling medical costs. Proponents and critics are also sharply divided on managed care's overall impact on the quality of U.S. health care delivery.
History
Paul Starr suggests in his analysis of the American health care system (i.e., The Social Transformation of American Medicine ) that Richard Nixon was the first mainstream political leader to take deliberate steps to change American health care from its longstanding not-for-profit business principles into a for-profit model that would be driven by the insurance industry. In 1973, Congress passed the Health Maintenance Organization Act, which encouraged rapid growth of HMOs, the first form of managed care.
Managed care plans are widely credited with subduing medical cost inflation in the late 1980s by reducing unnecessary hospitalizations, forcing providers to discount their rates, and causing the health-care industry to become more efficient and competitive. Managed care plans and strategies proliferated and quickly became nearly ubiquitous in the U.S. However, this rapid growth led to a consumer backlash. Because many managed care health plans are provided by for-profit companies, their cost-control efforts created widespread perception that they were more interested in saving money than providing health care. In a 2004 poll by the Kaiser Family Foundation, a majority of those polled said they believed that managed care decreased the time doctors spend with patients, made it harder for people who are sick to see specialists, and had failed to produce significant health care savings. These public perceptions have been fairly consistent in polling since 1997.
The backlash included vocal critics, including disgruntled patients and consumer-advocacy groups, who argued that managed care plans were controlling costs by denying medically necessary services to patients, even in life-threatening situations, or by providing low-quality care. The volume of criticism led many states to pass laws mandating managed-care standards. Complying with these mandates increased costs. Meanwhile, insurers responded to public demands and political pressure by beginning to offer other plan options with more comprehensive care networks--according to one analysis, between the years 1970 and 2005 the share of personal health expenditures paid directly out-of-pocket by U.S. consumers fell from about 40 percent to 15 percent. So although consumers faced rising health insurance premiums over the period, lower out-of-pocket costs likely encouraged consumers to use more health care. Data indicating whether this increase in use was due to voluntary or optional service purchases or the sudden access lower-income citizens had to basic healthcare is not available here at this time.
By the late 1990s, U.S. per capita health care spending began to increase again, peaking around 2002. Despite managed care's mandate to control costs, U.S. healthcare expenditures has continued to outstrip the overall national income, rising about 2.4 percentage points faster than the annual GDP since 1970.
Nevertheless, according to the trade association America’s Health Insurance Plans, managed care is nearly ubiquitous in the U.S.; 90 percent of insured Americans are now enrolled in plans with some form of managed care. The National Directory of Managed Care Organizations, Sixth Edition profiles more than 5,000 plans, including new consumer-driven health plans and health savings accounts.
Managed care techniques
One of the most characteristic forms of managed care is the use of a panel or network of health care providers to provide care to enrollees. Such integrated delivery systems typically include one or more of the following:
- A set of selected providers that furnish a comprehensive array of health care services to enrollees;
- Explicit standards for selecting providers;
- Formal utilization review and quality improvement programs;
- An emphasis on preventive care; and
- Financial incentives to encourage enrollees to use care efficiently.
Provider networks can be used to reduce costs by negotiating favorable fees from providers, selecting cost effective providers, and creating financial incentives for providers to practice more efficiently. A survey issued in 2009 by America's Health Insurance Plans found that patients going to out-of-network providers are sometimes charged extremely high fees. Other managed care techniques include disease management, case management, wellness incentives, patient education, utilization management and utilization review. These techniques can be applied to both network-based benefit programs and benefit programs that are not based on a provider network. The use of managed care techniques without a provider network is sometimes described as "managed indemnity."
Managed care organizations (MCOs)
There is a continuum of organizations that provide managed care, each operating with slightly different business models. Some organizations are made of physicians, while others are combinations of physicians, hospitals, and other providers. Here is a list of common MCOs:
- Group practice without walls
- Independent practice association
- Management services organization
- Physician practice management company
Types of network-based managed care programs
There are several types of network-based managed care programs. These range from more restrictive to less restrictive, and include:
Health Maintenance Organization (HMO)
Main article: Health Maintenance OrganizationProposed in the 1960s by Dr. Paul Elwood in the "Health Maintenance Strategy", the HMO concept was promoted by the Nixon Administration as a fix to rising health care costs and set in law as the Health Maintenance Organization Act of 1973. As defined in the act, a federally qualified HMO would in exchange for a subscriber fee (premium) allow members access to a panel of employed physicians or a network of doctors and facilities including hospitals. In return the HMO received mandated market access and could receive federal development funds.
HMOs are licensed at the state level, under a license that is known as a certificate of authority (COA) rather than under an insurance license. In 1972 the National Association of Insurance Commissioners adopted the HMO Model Act, which was intended to provide a model regulatory structure for states to use in authorizing the establishment of HMOs and in monitoring their operations. In practice, an HMO is a coordinated delivery system that combines both the financing and delivery of health care for enrollees. In the design of the plan, each member is assigned a "gatekeeper", a primary care physician (PCP) who is responsible for the overall care of members assigned to him/her. Specialty services require a specific referral from the PCP to the specialist. Non-emergency hospital admissions also required specific pre-authorization by the PCP. Typically, services are not covered if performed by a provider not an employee of or specifically approved by the HMO, unless it is an emergency situation as defined by the HMO. Financial sanctions for use of emergency facilities in non-emergent situations were once an issue; however, prudent layperson language now applies to all emergency-service utilization and penalties are rare.
Since the 1980s, under the ERISA Act passed in Congress in 1974 and its preemptive effect on state common law tort lawsuits that "relate to" Employee Benefit Plans, HMOs administering benefits through private employer health plans have been protected by Federal law from malpractice litigation on the grounds that the decisions regarding patient care are administrative rather than medical in nature. See "Cigna v. Calad ", 2004.
Independent Practice Association (IPA)
Main article: Independent practice associationAn Independent Practice Association is a type of HMO tha
Internet Care Directory
The Internet Care Directory is the Patient's Guide & Referral Service to Professional Health Care Providers The Most Comprehensive Listing of Professional Health Care Providers on ...
MHCP Provider Directory
Welcome to the Minnesota Health Care Programs (MHCP) Provider Directory. Use this directory to locate health care providers that serve fee-for-service MHCP clients.
Provider Directory - Arkansas Blue Cross and Blue Shield
... provider directory ... of Arkansas with more than 9,300 participating health-care providers.
NHP - Provider Directory
Find A Provider. Welcome to NHP's Provider Directory. Find a provider or hospital close to ... you and your family with the quality health care you expect. You can search for providers by ...
Health Care Service Provider Directory,India
Health Care Services India,India Health Card Provider Directory,Search Healthcare Providers in India,Healthcare Doctors in India,Healthcare Directory,Healthcare Service Provider ...
Minnesota Health Care Provider Directory
Health Care Facility and Provider Database. Access the directory of licensed and certified health care providers database. This database offers addresses, phone ...
Google Directory - Health > Home Health > Home Care > Service ...
Girling Health Care - http://www.girling.com/ A company providing in home care for patients including home health, primary home care, family care, and physical therapy.
Provider Directory : Health Advantage
Providers, please notify us if your directory listing ... covered by the BlueCard network for emergency or urgent health care while ...
IL Provider Directory Welcome
The Illinois Provider Directory for Children with Disabilities is an online resource to locate health care providers serving Illinois children with special health care needs.
Health One Alliance Provider Directory
This directory includes all providers in the Health One Alliance Network. ... of using this provider locator Website or receiving care from a provider ...