Managed care

Managed Care Excessive medical expenditure is the major characteristic of American Healthcare System. Recently it has become the center of American politics with the introduction of the Obama’s Health Plan. ‘ Managed Care’ is the dominant health care delivery method in the United States that emerged since the Health Maintenance Act (HMO) of 1973. The new system was expected to ensure quality care and control over the escalating health care cost. There are various Managed Care models like HMO, PPO, POS, and FFS which offer financing, insurance, delivery and payment for health care services.
Accreditation is the significant process that Managed Care Organizations (MCOs) need to pass in order to prove their credibility and quality. Both, service providers and customers consider the certification as highly important because it indicates that an organization has attained the standard of quality defined by the accrediting agency. The major Accrediting Agencies in the United States are ABQAURP, NCQA & HEDIS, The Joint Commission, AAAHC & AAAASF and URAC.
Although the criteria for accreditation vary depending on the type of Managed Care Organizations and the accrediting agency, there are certain common factors that are applicable in the review. The Agencies usually consider the “ MCO’s quality management program and its impact on operations, at utilization management and how it is carried out, at the MCO’s treatment of members and so forth.” (Kongstvedt., 2003 p. 239).
TRICARE is a managed care option of Civilian Health and Medical Program of the Uniformed Services (CHAMPUS) initiated by Department of Defense (DOD). The service has been delivered through its worldwide Military Health Service System (MHSS). DOD provides Tricare civilian health benefits for military personnel, military retirees, and their dependents through its 11 health service regions. It has also established a new administrative structure to supervise the delivery of health care. (Kongstvedt, 2003 p. 1131). Tricare Standard (Fee for Service Program), Tricare Extra (Preferred Provider Option), Tricare Prime (HMO Option), US Family Health Plan, and Tricare Reserve Select (TRS) are some of the major plans of Tricare. As compared to other managed care services in the United States, Tricare offers more steady high quality health care benefits and reduced costs. Tricare service is accessible according to the priority of the beneficiaries as follows; active duty members, family members of the active prime members, retirees and their family members, family members of the active prime members but not enrolled, and finally all other beneficiaries. (Farely, Harris, Ashwood, Cherry, Dydek, Carleton, 2003 p. 4).
However, irrespective of the numerous managed care plans, healthcare remained to be inaccessible to common people. The major drawback of the managed health care is that it has turned to favor insurance companies instead of favoring the customers. In addition, providers tend to ‘ minimize uncompensated care and continue with the treatment of the uninsured patients; and hospitals merge to achieve greater economies and contract with managed care organizations’ (Davis J R., 2002 p. 57). Moreover, the quality of managed care often does not reach the expected range (Verheijde, 2005, p. 156).
In this context, healthcare reform is relevant to ensure affordable, high quality coverage. The President thinks that it would be possible by enhancing competition between a public insurance program and the private firms. He proposes a system that would force companies to reduce their premium rates in order to compete with the subsidized rates of public insurance.
References
Davis J R. (2002). Managed care System and Emerging Infections: Challenges and Opportunities
for Strengthening Surveillance, Research and Prevention. National Academies Press.
Farely, Harris, Ashwood, Cherry, Dydek, & Carleton. (2003). Evaluation of the Medicare-DoD
Subvention Demonstration. Issue 1580. Rand Corporation.
Kongstvedt P R. (2003). Managed Care: What It Is and How It Works. Jones & Bartlett
Publishers.
Verheijde. (2005). Managing Care: A Shared Responsibility. Issues in Business Ethics. Springer.