Health Care Delivery: Deciphering the Managed Care System

The concept of traditional health care has now been replaced by the concept of Managed Care Organizations (MCOs). In a more traditional from of health care delivery patients had the freedom to see the physician of their choice. Physicians were able to order whatever services they felt were necessary. Health plans were mostly set up as passive parties who paid for all services that a physician ordered at the provider's usual charge (http://www/mcareol.com/factshts/factover.htm, 2003, para 2).

The delivery of health care is now a lot more complex in the managed care system. Managed care is a system that involves the coordination and arrangement for health services and coverage of health benefits. Some of the most common types of Managed Care Organizations include Health Maintenance Organizations (HMOs), Preferred Provider Organizations (PPOs), and Exclusive Provider Organizations (EPOs). Managed care generally consists of three main components: oversight of medical care provided; contractual relationships and organization of the providers giving the care, and the covered benefits associated with managed care rules (http://www.mcareol.com/factshts/factover.htm, 2003, para 1).

In the last decade managed care has become the most used form of health insurance in the United States. There are over 51 million people who are enrolled in health maintenance organizations, better known as HMOs. This is the most organized form of managed care (http://www.consumers.org/q&anet.htm, para 2).

The biggest question that arises when dealing with the managed care delivery system is if the quality of service seems to vary according to each plan. There is no guarantee that the services provided through each plan will be any better or worse than the next. Though managed care provides a wide range of services it is difficult for many of the sickest individuals or other at-risk groups to receive the care that they need. There is a great potential that access to needed services could be impeded my managed care. This is one of the largest consumer concerns when dealing with MCOs. This causes the need for a great deal of monitoring when it comes to the quality of care being provided (http://www.consumers.org/q&anet.htm, para 3).

According to the American Medical Student Association, or AMSA, there is a lengthy list of established principles regarding health care delivery and delivery systems. When it comes to managed care the association, "opposes the concept that fee-for-service practice, in the context of medical care as a market commodity, is the only system to provide the highest quality and availability of medical care." In other words it is believed that managed care can still be an effective health care delivery system even though it does not function on a fee-for-service basis (http://amsa.org/about/03ppp/delivery.pdf, para 2).

The AMSA also believes and supports the idea of group practice as a model that is able to increase the quality of health care delivery to everyone. They also support, "the establishment of community-based, community-controlled health-care system, publicly financed through general revenues and progressive taxes, employing a full range of health workers and providing complete health services." This is basically stating that managed care should still work in cooperation with other government based health care insurances such as Medicaid and Medicare (http://amsa/org/about/03ppp/delivery.pdf, para 2).

The final point of the AMSA is that it, "opposes the current profit-based fractionalized health-care delivery system." This statement is probably one of the most powerful made by the AMSA regarding the managed care system. Many people do not like to think of health care delivery as a profit-based business. In a perfect world everyone would like to be able to receive the necessary health care, but unfortunately health care is actually a business just like any other (http://amsa.org/about/03ppp/delivery.pdf, para 2).

The concept of managed care seems to work well for everyone except the patient. For example, a patient may know that they want to be tested for allergies, but before they can do that they will have to generally go through an assigned doctor to receive a referral to do so. This may cause a delay in the ability for the patient to receive the requested appointment. This may not seem like a big problem for a simple procedure, such as allergy testing. On the other hand, if a patient needs to see a more advanced specialist they could have an extensive wait, which could ultimately affect their health even more. If a patient chooses to not jump the hoops of managed care they will be penalized financially. This can make it very difficult for a patient to receive any higher level of care.

The most important point for anyone to realize when dealing with health care delivery is that the more freedom you want the more money you will pay. If you are willing to follow the rules and be patient managed care can work. If you do not want to deal with limitations you will pay more money out of your own pocket. The idea of managed care is to control costs for everyone including insurance companies, medical providers, and patients. Unfortunately this concept does not always work to a patient's advantage. It would seem that the idea of having a patients' care managed would be very organized and would actually work in the patient's favor. Unfortunately the concept of managed care only works if everyone involved agrees to play by the same rules. Just like anything else in life if you do not follow the rules there will be a price to pay. These penalties can range from not getting the care that is needed to a great financial burden.

No matter what form of health care delivery is being used it is always important to make sure the rules are clearly understood and followed as much as possible. This applies to everyone including the physicians, insurance companies, and the patients. This is the only way to insure that everyone involved in health care delivery will be able to utilize the system to the best of its abilities.

References

The American Medical Student Association. Retrieved December 10, 2003 from the World Wide Web http://amsa/org/about/03ppp/delivery.pdf

Managed Care Fact Sheets Overview. Retrieved December 10, 2003 from the World Wide Web http://mcareol.com/factshts/factover.htm

Questions and Answers about Managed Care. Retrieved December 10, 2003 from the World Wide Web http://www.consumers.org/q&anet.htm