Managed Care Model Essay

Managed Care Essay

Managed care is a part of American healthcare system. Managed care became very popular in the Reagan era. This system was originally used in order to control Medicare payout. Medicare became the only state governmental health insurance program. It covered all people over 65 years and provided them a number of free medical services. So, managed care was used in order to control Medicare payouts. There are a big number of health insurance programs, which are used for managed care. Managed care is originally designed in order to reduce the costs of unnecessary health care. This result is achieved with the help of different mechanisms, such as economic incentives aiming to make physicians and patient choose cheaper forms of medical care; special programs, which check up the necessity of some specific services; control over the length of treatment; cost sharing incentives for outpatient surgery and many others. These kinds of programs can be provided by different organizations, such as Preferred Provider Organization of Health Maintenance Organizations.

Managed care assumes that health care organizations make arrangements with doctors, hospitals and other provides or medical service themselves. In the middle of 1990s there was noticed a decline of managed care. There are many factors, which influenced this situation but economical factors caused the strongest influence (Reinhardt). Managed care originally developed under the influence of recession, which took place in 1990s. Karim Habibi, a director of the managed care at the Hospital for Joint Diseases Orthopedic Institute in New York City states that “During that period, employees were concerned about losing their health care coverage. Employers were successful in reducing health care expenditures by controlling health care demand, which was achieved by restructuring health benefits and limiting employees’ health care supply” (Habibi). Designed originally as means to control medical costs, managed care failed to perform this function. In the 1990s employers significantly reduced guarantees and medical care insurances, provided by the organizations to its employees. During this time the Health maintenance organization appeared. This organization was designed as means to reduce the medical costs. This result was achieved through the use of aggressive utilization programs. “That, coupled with aggressive managed care utilization programs, enabled HMOs to flatten health care increases between 1993 and 1997” (Habibi). Such a policy resulted in a confrontation between patients, health care providers and payors. The situation resulted in crises, when several states enacted the health care bill of rights. This bill was aimed to defend the rights of the patients. According to some main points of this bill, patients had the rights to know about all possible variants of treatment and could not be refused necessary health care without the considerable reasons. So, all efforts to reduce medical spending, which were successful in the 1990s does not work any more. Starting from the 1998 the medical costs grow considerably, and there are several reasons for such a growth. Growing costs of drugs, technological advances in the field of medicine, and inflation are among the main reason of these growth.

Since this tendency is going to grow, most probably we can speak about the reduce of the importance of managed care. Most probably it will not gain such power as it used to have in the 1990s. Nowadays we can speak about the decrease of its importance. At the present moment consumer of the medical services choose plans, which are more suitable for them. Preferred provider organizations and points of service plans provide them kind and quality of services they like best.

References

  • Scandlen, G. (2005). Consumer-driven health care: Just a tweak or a revolution? Health Affairs 24(6), 1554. Retrieved on August 29, 2007 from Proquest.
  • Habibi, K. (2001). Evolution of Managed Care. Retrieved on August 29, 2007 from http://www.orthopedictechreview.com/issues/novdec01/editorial.htm.
  • NCQA (2007). Managed care Organizations, Accreditation MCO. Retrieved August 23, 2007 from http://web.ncqa.org/tabid/67/Default.aspx.
  • New York Health Plan Association (n.d.). Managed Care vs. FFS Chart. Retrieved on August 29, 2007 fromhttp://www.nyhpa.org/AboutHMOsinNY/ManagedCareVs.FFSChart.asp.
  • URAC (2007). General Questions About URAC Accreditation. Retrieved on August 29, 2007 from http://www.urac.org/accreditation/
  • Gitterman, D. P. (2000). The president and the power of the purchaser: Consumer protection and managed care in the United States.
  • California Management Review 43 (1); 103. Retrieved on August 29, 2007 from Proquest.
  • Tietze, M. F. and Sinha, S. K. (2003). Impact of managed care on healthcare delivery practices: The perception of healthcare administrators and clinical practitioners / Practitioner application. Journal of Healthcare Management 48 (5); pg. 311. Retrieved on August 29, 2007 from Proquest.

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Good nurses also teach doctors. The nurses in specialized wards like the intensive care unit are some of the best-trained professionals in the hospital. When I was an intern, they taught me how to put in catheters and adjust ventilators. They told me which medicines to avoid. They taught me how and when to initiate discussions with families about end-of-life treatment.

Nurses provide essential psychological and emotional support to patients, because they are the ones who spend the most time with them. And nurses are in the best position to judge minute-to-minute changes in a patient's medical condition. Rarely do I respond faster than when a nurse I trust tells me I must see a patient right away.

Over the summer, the union representing 1,600 nurses at the Columbia Presbyterian Center of New York Presbyterian Hospital threatened to strike over staffing shortages that forced many of them to work double shifts and weekends. Because good nursing is so critically important for patients, many argued that such a strike would be unethical, if not unconscionable. I take a different view.

It ought to go without saying that nurses, like any health-care professionals, provide better care when they are satisfied with their jobs and are not overworked. But these days, such conditions are not easy to find. Managed care and government cost-cutting measures have hit hospitals hard, and many have cut staffing to the bone. Some nurses in New York hospitals routinely take care of 8, 10 or more patients at a time, a monumental task given the monitoring and medication that sick patients require.

Congress first awarded collective bargaining rights to nurses in public hospitals in 1947 through the Taft-Hartley Act. But the American Nurses Association had a no-strike policy until 1968, when its House of Delegates voted to allow state nurses' associations to set their own strike policies.

That year, Barbara Schutt, then editor of the American Journal of Nursing, wrote in an editorial in support of that decision: ''Anyone who knows nurses knows that few will use the strike weapon easily, and that if they do, they will use it responsibly -- with adequate notice and plans to provide emergency care.''

This has indeed been the case. There is no record of any patient's dying as a direct result of a nurses' strike in the United States. Nurses are required to give a 10-day notice before a strike so hospitals can stop elective admissions and plan for emergency care.

During a wide-ranging strike in Minnesota in 1984, the Minnesota Nurses Association met with hospital administrators before a strike to determine emergency requirements. When the strike took place, some nurses crossed the picket line to help doctors handle emergencies, with the full approval of the union.

In the 10-day period this summer leading up to the strike deadline, many patients requiring routine care were transferred to New York Hospital, Columbia Presbyterian's sister institution. This minimized the turmoil a strike would otherwise have brought on.

Still, nurses often experience a conflict between the moral imperatives of their jobs and the practicalities of their lives. They have families and financial concerns like anyone else. Most nurses I have spoken with at New York Hospital have a characteristically divided stance with regard to striking. They think it may be unethical, but may still be necessary.

One nurse said she believed that nurses' first priority must be to their patients. ''But what are nurses supposed to do,'' she asked, ''if hospitals don't let them be good nurses?''

In the end, of course, the nurses decided not to strike. Just 90 minutes before the walkout was to begin, the union accepted a compromise giving nurses a say in deciding staffing levels and letting them work, for the most part, three days a week in 12-hour shifts.

It was a welcome compromise, one that could probably not have been achieved without the threat of a strike. And it was a welcome lesson for other hospitals. In New Zealand, Italy and other countries, work stoppages by nurses have forced hospitals to increase personnel and decrease patient load. In Japan, nurses dressed in white took to the streets in the early 90's to demand more personnel and less night duty. Hospitals in the United States need to address nurses' concerns now, before strikes seriously undermine patient care.

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