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Managed Care Organizations Case Study

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The evolution of managed care organizations has created a dramatic change in our health care system. In 1995, about 161 million American citizens, were enrolled into a managed care organization plan. Some of the plans under the managed care are health maintenance organizations (HMO), preferred provider organizations (PPO), point of service plans (POS), and other networks such as Exclusive Provider Organization (EPO), and union plans. All these plans are different from one another in regards to organization structure, reimbursement for providers, types of services, and care access strategies. However, the goals established by managed care are to reduce and control cost of medical and behavioral health services through case management or care …show more content…

Once the private and public sector agencies provide these members to a managed care organization, and their responsibility is to be responsive to the care of their member and the health care system. For these managed care organization to fulfill this they need to be accredited, licensed, certified, credentialed, meet guidelines, report card based on services, performance measures. However, all these requirements for a managed care to create a model of care but I believe the behavioral/mental health services are still not meeting …show more content…

The public sector is funded and financed by the state and government for Medicare and Medicaid coverage and broad range of different medical services and treatments. As for the private sector it shares different structures but collaborates and often corresponds with public sector amenities. Some of the private sector examples are employee assistance programs in the workplace, and managed behavioral health and they are starting to associate with public organizations to help patients.

Other federal supported systems like the U.S Department of Defense (Tricare) and U.S Department of Veterans Affairs (VA) share both private and public sector care systems but different care service systems. Also, care services are also different for children, Native Americans, and seniors. As a result, of having a higher number of self-governing delivery organizations aiding other populations under different fund aids it causes difficulty assessing to improve quality of

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Your choice of providers may be limited to those within the network, or your out-of-pocket costs will be lower when you obtain services from providers within the network. A managed care plan is an arrangement with a selected network or group of organizations; it is evolved as a way to reduce the cost of health care and improve the quality of care using a variety of techniques. In other words, managed care is a technique to bring the health insurer, health care providers, medical facilities as well as the individual who wants to be insured just under one umbrella. Under fee for service plans this type of health plan, the health insurer is liable to pay the claimed bills of health care services provided to a policyholder.

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Sector One Healthcare Group About Us We are a Nationwide Consulting Group Sector One Healthcare Group is a healthcare consulting group that offers a full range of services throughout the United States Our Mission is to… Assist federally qualified health centers (FQHCs), private practices, and mental health centers/organizations (MHCOs) thrive. Our Vision is… To be the premier federally qualified health center (FQHC), private practice, and mental health center/organization (MHCO) consulting group, which they rely upon to assist them grow and continue to be an integral, dynamic part of an evolving health care system To be the foremost strategic partner to ensure that everyone will have the opportunity to choose a health center, private practice,

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Public health has serve under advantage people for several years. According to the article, many public health agencies provide services such as prenatal education and counseling, childhood and adult immunizations, family planning and birth control, chronic disease screening, and diagnosis and treatment for sexually transmitted diseases, HIV and AIDS, and tuberculosis. According to the article many public health agencies also offer outreach and support services such as transportation, on-site child care, and home visiting that are designed to encourage appropriate use of these services. I feel that this is important to be able to offer transportation assistance and children care for some of the percipients.

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Some variability differs with the capability of providing out-of-network health providers and the services in which can be provided. By having a broad range of choices that can be provided, will cause a higher the cost for the individual that is paying. Most Medicare patients have received the managed care plans due to promises of a lower copayment amount and often medication benefits. Medicare post-acute spending has grown rapidly with the number of users between 1999 and 2007. The growth in Medicare short-term post-acute service use, in part, reflects short hospital stays and a growing demand for rehabilitation services.

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Like HMOs, the lynchpin in the ACO will be the primary care physician. However, unlike the current system, the network of doctors and hospitals will be rewarded for keeping costs low while providing the best possible service to patients. Indeed, bonuses will be paid to members of ACOs who manage to adhere to this decree. For those hospitals and doctors who already have a favorable balance of low cost and excellent care, the ACO model should prove easy to move into and would, in fact, compliment an already existing system. For those who are not performing to the standards of this mandate, the ACO requirement will offer encouragement – prodding, even – to conform to the higher set of standards.

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Organizations are not simple to evaluate. In fact, they are complex environments that require a multitude of efforts and perspectives to be as effective and efficient as possible. These different perspectives are what scholars use to judge how well an organization is progressing with the attainment of its goals. This paper will focus on Spectrum Healthcare, a non-profit organization, and how well it accomplishes its goal. Beginning with a short history of the organization, then followed by an analysis of multiple organizational perspectives of, it can be concluded that Spectrum Healthcare is effective in attaining its goal, YOU.

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Managed behavioral health organizations (MBHOs) allowed price competition in healthcare, thereby affecting the economics of mental health professionals and hospitals (Smith, 2012). With the increase in prices, mental health care demand drastically decreased. To alleviate the issue, there were several attempts made to extend insurance coverage to mental illness. Then in 1992, counseling was added to health care human resources by NIMH (Gladding & Newsome, 2010). During this time, Community counselors and others encouraged healthcare, while Mental health counselors advocated to be recognized as a profession and not mental health care providers.

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MCO- Managed Care Organization An organization formed among Primary care Physicians, and specialists to work under Health Maintenance Organization and Preferred Provider organization with aim of improving quality of care and improve health benefits. Concierge Medicine Also known as Retainer Medicine maintains the relation between the patient and their primary care physician by which patient is forced to pay maintenance fee to Primary care Physicians to receive services. Main advantage is it limits number of patients so that PCPs can spend quality time with patient. E&M CODES- Evaluation and management coding Evaluation and management coding are 5 digit current procedural terminology codes that will help in billing the patient-physician encounters.

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By the 1950s, the World War II era was over and the payment for healthcare has changed. With fewer patients paying out of pocket and more patients being insured (Fuchs, 2012). Medicare and Medicaid program was created in 1965. Medicare and Medicaid plans accounts for 32% of medical spending. During the 1980’s and 1990’s, the cost of health care rose rapidly and the majority of employer-sponsored group insurance plans switched from “fee-for-service” plans to the cheaper “managed care plans.”

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Employers within the private sectors are proclaimed to be key drivers in regard to the changes that have occurred in the healthcare system. These employers have learned how to shift the purchasing power of paying for open ended fee for service health coverage benefit to purchasing health care, on a capitulated basis, from plans where the care was managed. The amount of employees in the private sector that are enrolled in a form of managed care has grown from 29% in 1988 to around 70% in 1995.(Cite) Employers now believe that there is better chance of saving without altering the quality of care given. Employers now have an expectation that instead of an increase in premiums, the cost of managed care plans fall or remain at moderate levels.

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At first I always believed that Managed Care was more business orientated, which focused on the finances rather than the actual healthcare. For example, there has always been controversy on the for- profit trend in the health care system. There has been cases where non for-profit health care plans have changed into for- profit plans because of demanding competition. Managed Care can also be a nuisance for those who want a different physician but their managed care provider does not cover that particular physician. It is extremely irritating when a physician refers you to a specialist who is not part of your care network.

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