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Pros And Cons Of Managed Care Organizations

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You have now learned that there are various forms of Managed Care Organizations. As a purchaser of health insurance, which form is more appealing to you? Discuss the pros and cons of your choice.
Please provide specific, referenced examples in your discussion.

HMO’s and PPO’s are typically marketed the most. However, there isn’t the “perfect health plan type”. Each type is just a different balance point between benefits vs restrictions, and between spending a lot vs spending less. I personally like the POP plans, as it seems to allow me a greater ability to select my healthcare provider. Though a POS plan sounds rather attractive.As Davis defines a POS as, “POS stands for point of service plan. POS plans resemble HMOs but are less restrictive in that you’re allowed, under certain circumstances, to get care out-of-network like with a PPO. Like HMOs, many POS plans require you to have a PCP referral for all care whether it’s in or out-of-network (Davis,2016). Therefore, with any healthcare decisions, an individual must look at what their essential healthcare needs are. I like many others question this on a daily basis in regards to my healthcare needs. However, as Davis also indicates that there are 6 preferred basics that we must analyze.
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Whether or not you’re required to have a primary care physician.
2. Whether or not you’re required to have a referral to see a specialist or get other services.
3. Whether or not you have to have health care services pre-authorized.
4. Whether or not the health plan will pay for the care you get outside of its provider

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“Renee Laux & Laura Jean Cataldo (2013) reports A major disadvantage to the patient of an HMO is that his or her preferred health care provider may not have a contract with that HMO and therefore, if the patient wants to see that particular provider, he or she would have to pay for the visits out of pocket. Another disadvantage of HMOs can be that providers may end up being at a financial disadvantage because of the reduced fees required to contract with the HMO. In some areas, this has led to very few healthcare providers contracting with certain HMOs and thus the members of the HMO have very little choice in whom to see.”

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Managed Care plans are also known as prepaid health care plans. Managed healthcare plans strive to deliver high-quality healthcare, while controlling cost. Services and fees are negotiated with healthcare providers and facilities to provide access to otherwise expensive healthcare services to patients. Services under listed within the Managed Care plan monitored continuously to ensure that all services are provided in the most cost effective manner. An HMO or Health Maintenance Organization is an example of a Managed Care Plan.

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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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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

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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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If a patient wants to see a doctor of their choice, that may be out of network then the patient would need to pay for those services out of pocket. Also with a managed care plan there is a “lifetime cap” that is the allowed benefits that a patient can receive during their lifetime. If a patient reaches that cap, then there is no additional coverage through the plan and all the expenses would need to be paid out of pocket by the patient. (Benefits & Disadvantages of Managed Health Care) Medicare Medicare does have specific restrictions within the

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MCO’s (managed care organization) and HMO’s are essentially the same thing. They allow for provision of care to a group of insured members. PPO’s permit out-of-network appointments sans referrals and give the freedom to choose from several providers. IPA’s are a group of physicians that are contracted with an HMO/MCO plan to care for HMO/MCO patients. (Ex: Kaiser is not an IPA-HMO provider, where Sigma is) 15.

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The primary reason why the managed care model was created to provide satisfactory and best healthcare to all the enrollees at reduced and controlled cost and its aims to ensure that the healthcare provide a suitable medical condition of the patient and safeguarding such services are provided by appropriate provider. Its emphasis on keeping enrollees healthy to reduce use of services. The two types of Managed Care is Preferred Provider Organization (PPO) the other one is Point of Service (POS) plans. The difference with the PPO is that this is not a restricted as the HMO plan and allows people to approach providers outside of the network.

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You are a new physician setting up your practice in a new town. You are researching the different MCOs offered in your area and are considering becoming a physician for one of these networks. You have also invited the sales representatives of several healthy plans to speak with you about the benefits of choosing their plans. Based on the above scenario, answer the following questions: • What effects would join an MCO have your clinic regarding staffing, patient volume, and financial stability?

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the states regulate the business of insurance, which includes the MCO (such as a health maintenance organization (HMO)) that offers a managed care policy to an individual, employer, or other purchaser. If a private sector employer sponsors a plan that is not purchased from an MCO (i.e., the plan is self-insured), The details and the extent of these state laws vary considerably, but they remain in force as a mechanism for regulating HMOs and other forms of managed care organizations. A number of states require managed care plans to provide current and new enrollees the opportunity to continue to receive care and services for a period of time with a provider that has been terminated or dis-enrolled from the plan. Many states call for health plans to institute procedures that provide an enrollee that requires specialized medical care over a prolonged period of time to receive a standing referral to a specialist. Many state laws specify automatic coverage for emergency medical conditions "of sufficient severity, including severe pain, that a prudent layperson, who possesses an average knowledge of health and medicine, could reasonably expect the absence of medical attention to result in placing the person’s health in

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