MANAGED CARE

Managed Care

Table of Contents

Introduction1

Issues1

Managed Care Laws in US1

Employee Retirement Income Security Act of 1974 (ERISA)2

Consolidated Omnibus Budget Reconciliation Act - COBRA2

Gag Clause2

Conclusion3

References4

Managed Care

Introduction

The literal meaning of managed care can be traced backed to 19th century when a small number of physicians agreed to provide prepaid medical facilities to the member of fraternal orders, unions, and other associations of workers. Organizations provided with unlimited access to health care with a minimal amount of the annual fee. In the next half of 20th century, the federal government and many large private were encouraging the growth of prepaid health policies. This growth in managed care segment boosted up in early 80's and during 90's it improved its share.

Currently 170 million Americans are receiving health care coverage or benefits through "Managed Care" settings. By 2007, about 20% of these services, are directly provided by a health maintenance organization (HMO), while the majorities served through other managed arrangements, 60% in Preferred Provider Organizations (PPO) and 13% in Point of Service (POS) plans (NSCL, 2008). According to HMO (Health Maintenance Organization) Act of 1973, whose main aim is to provide, grants and loans to assist in the startup of health maintenance organizations. At Present, Many organizations registered themselves, to provide a variety of health benefits to their employees, with an approx estimation of 90% of people involved in these programs, in one way or the other.

Issues

A number of amendments to Health Managed Care - Laws were done, keeping in view the impacts of providence of medical care given to the patient or employee. Many Issues had been reported in negative as well as a positive aspect towards this issue. Managed Care Organizations were posed to design the policies in a way to facilitate effected people.

Some of the issues that people typically face are of physicians as “Gatekeepers”, which limit access to care. MCO's usually nominate their own recommended physicians and hospitals, irrespective of ease of access to employee. Therefore, employees get bounded to go only to recommended places. Similarly, the practitioners may be short of the essential skills or expertise to deal with medical requirements of people with various physical and cognitive disabilities.

MCO's (Managed Care Organizations) emphasize more on significant care and cost inhibition, therefore, they are unable provide the diagnoses for treatment of conventional health care conditions. Further they usually do not cover for the usual medical need for people, For example, dental and seasonal care. Managed Care Organizations are primarily paying for hospitalization or accidental need of employees, which is in a very rare case.

In addition, there is a convolution in MCO's medical appointment procedures and complaints processes. Employees have to go through proper testing, screening and loads of paper work, before being eligible for the grant. Most of time, people who were diagnosed with some minor ailment before employment, were cut short of grant due to preceding illness. Beside this, employees were required to pay the initial fee at emergency and have to go through a ...