Health sciences and medicine

compare and contrast Managed care

Purpose
To assess your ability to compare and contrast the types of managed care.

Due to increasing regulations combined with rapidly changing economic and legal forces, the healthcare industry is constantly experimenting with new forms of healthcare delivery and reimbursements. Health Maintenance Organizations (HMOs) started to grow in the 1970s followed soon thereafter by Preferred Provider Organizations (PPOs). Each of these managed care systems attempted to adjust to the changing environment and find a reasonable way to navigate the uncharted waters of government regulations and increased economic demands with the realizations that there were financial limits. Then the political landscape changed and demanded greater choice and access to the best possible healthcare and at a low price. To find the right mix, medical staffs and hospitals organized into joint ventures, doctors competed with hospitals by establishing freestanding emergency clinics or urgent care facilities, and insurers experimented with innovative reimbursement and prospective payment systems.
In PPOs, insurance companies or employers provide incentives to enrollees to obtain medical care from a panel of providers with whom the payer has contracted a discounted rate. Exclusive Provider organizations (EPOs) use a gatekeeper approach to authorizing nonprimary care. The primary difference between an HMO and EPO is that the former is regulated under HMO laws and regulations, whereas the latter is regulated under insurance laws and regulations.
An Independent Practice Association (IPA) generally contracts with an HMO or a physician hospital association (PHO). The physicians maintain their own practices and do not share services such as claims, billing, scheduling, and accounting. A Management Service Organization (MSO) is an entity that provides administrative services to physicians. The organization performs such services as practice management, marketing, managed care contracting, accounting, billing, and personnel management. The goal of hospital-physician integration is to provide a full range of services to patients. A vertical Integrated Delivery System (IDS) achieves this goal, providing services ranging from primary outpatient care to tertiary inpatient care.
The standards for HMO federal qualification were introduced in 1973 when congress enacted Title XIII of the Public Health Service Act, known as the HMO Act. This law was intended to foster the growth of HMOs, which were considered to be a cost-effective method of healthcare delivery.

Action Items

Reflect on the Overview information above.
Participate in the discussion led by your professor that compares and contrasts the types of managed care.
By Wednesday, post your initial response (minimum 300 words) on the discussion topic, Compare and Contrast Managed Care.

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