Managed Care Plans - Term Paper Example

 Managed Care Plans Abstract Recent past has seen a growth in managed care as a principal method of providing healthcare in the United States. Managed care systems tend to assume the role of provision and financing of healthcare, and, in the process, they pose problems to healthcare professionals. The primary health care professional has been used in a similar position as a gate keeper charged with the responsibility of patient care as well as containing costs (Sing, Banthin, Selden, Cowan and Keegan, 2006). A host of pundits have argued that the new line of medicine poses a huge threat to the role played by healthcare professionals like physicians. They have argued that a new system or model of the patient-physician relationship should be implemented so as to contain the changes in financing of healthcare. This paper aims at looking at the issues arising as a result of managed care plans, as well as their impacts on healthcare practitioners/professionals. Managed Care Plans The general understanding of managed care’s impacts on healthcare practices is evolving. Medical ethicists, lawyers, clinicians and a host of observers have voiced their concerns over the issue of patient-physician relationship, the ethical obligations of the physician and the quality of care provided. In addition, Cox (2006) asserts that physicians have come out loud to write about their experiences with managed care practices. Professional societies including the AMA (American Medical Association) issued guidelines on how to respond to the challenges posed by managed care to healthcare professionals. The cost of healthcare has risen in the past decade, and, as a result, calls for healthcare systems that are cost effective. Many healthcare insurers are adopting the managed care policies and/or principles (Cox, 2006). The U.S, in particular, has seen a rise to a number of managed care plans/arrangements in the healthcare system among them being the Independent Practice Associations (IPAs), group and staff model Health Maintenance Organizations (HMOs), as well as Preferred-Provider Organizations (PPOs) (Trends, 2009). Issues in Managed Care Managed plans employ several techniques; some directed towards the behavior of the professional while others directed at those who have pledged to the plan. For instance, Cox 2010) affirms that managed care covers a wide range of primary and preventive healthcare services. As a result, Anatomy (2011) believes that their managed care plans are aimed at encouraging the subscribers to these plans to seek medical care in cases where it is still possible to control or prevent the occurrence or development of a given disease or illness. Furthermore, subscribers are restricted to healthcare practitioners who have accepted to be reimbursed at lower rates or rather exhibits a trend of provision of healthcare at low costs. Recent years have seen patients separated from experienced and highly proficient professionals in large de-selection activities of the managed care plans (Cox, 2006). In addition, Cox (2010) reveals that managed plans can take charge of the behavior of subscribers via denying them services of a medical professional before they are approved by the primary professional. Managed plans have a considerable impact on the costs of the practices by physicians in healthcare provision. Often, Banthin, Cunningham and Didem (2008) argue that the plans constrain the ability the physicians have to carry out certain routine procedures or inquire for particular diagnostic tests or medications. An example is a case where a physician has to receive approval from a radiologist before they can commence with a test or a case where the managed care plan excludes a number of costly medications from the formulary of the plan (Banthin, Cunningham and Didem, 2008). At times, managed care plans reduce costs via the creation of the economies of scale, coordination of care among hospitals and healthcare professionals and establishment of information systems to provide an improved measurement of efficiency and quality in the field. Managed care plans are the source of physicians’ cost-effective decisions via the use of financial spurs (Banthin, Cunningham and Didem, 2008). The plans tend to compensate healthcare practitioners with capitation salary as well as implement incentives for physicians to control the use of ancillary services, diagnostic tests, referrals to fellow practitioners or hospital care. An example is where a plan pays bonuses to healthcare professionals. The bonuses are subject to increment with proportionate decrease in the expenditure of the plan on healthcare of patients. Other plans withhold a certain percentage of the compensation designated to the physician until the year ends so that it can be used to cover for any shortfalls of the planned expenditure of the plan on the provision of patient care. In case the physician took good charge of the costs and, as a result, there are no shortfalls as per the expected expenditure of the plan, or there is a short fall which can be covered by a fraction of the withheld amount, the remaining amount is returned to the healthcare practitioner. The Impact of Managed Care Plans on Health Information Management Medical records have previously been developed for business purposes for an individual provider of healthcare (Loots and Johnson, 1995). Today, medical records have become a necessity as it supplies information that is vital for continued care of a given patient and is subject to state and federal regulations with ownership of the document being entitled to both the healthcare provider and the patient. As a result, Trends (2009) believe that health information management professionals are affected by this transition in that there is increased emphasis on the importance associated with documentation or rather record keeping during a health practitioner’s medical training. Owing to the increasing participants in the field of healthcare delivery as well as the intricacy of the participating organizations, a need for development of a law regarding the management of health information developed (Banthin, Cunningham and Didem, 2008). Traditional medical records professionals have always been performing tasks that are highly quantitative with total focus on the departments. However, Banthin, Cunningham and Didem (2008) argue that the managed care plans present these record managers with a challenge that sees them adopt the new systems approach to the management of health information. Roles of a Traditional Health Record Professional As earlier noted, traditional health management activities or rather professionals engaged in quantitative tasks that were departmentally focused. According to Sing et al. (2006), a majority of the activities carried out in traditional management of health records include forms control, controlling and analyzing contents of medical records, tracking of the medical records, release and monitoring of medical information, storage of medical records as well as destruction of the non-required medical records. Today, with the managed system of care these activities carried out within an outsized and assorted healthcare organizations where problem solving and making of critical decisions address the whole system and not an individual (Banthin, Cunningham and Didem, 2008). Traditionally, a host of issues affected the processes of collecting, maintaining, and retrieving or accessing information in medical records (Cox, 2010). With the introduction of the new systems of managed healthcare, the information in these medical records can be easily collected, maintained and retrieved or accessed since most if not all of it is stored electronically (Sing et al., 2006). Healthcare Information Management professionals are charged with the duty of maintaining the medical records. With the widespread computer automation of these traditional processes as well as increased accessibility to various sources and types of information, professionals in the healthcare management of information are faced with the difficulty of protecting the information of patients (Cox, 2006). Similarly, Cox (2010) reports that a host of legal issues have arisen that affect the management of healthcare information. Medical record practitioners are charged with the responsibility of safeguarding the medical records of a given medical facility as well as ensuring high levels of confidentiality are maintained (Trends, 2009). Managed medical care has reduced the dominance of hospitals as the sole health record keepers (Cox, 2010). Medical care takes into account the activities of all medical practitioners; ranging from primary healthcare practitioners and/or providers, specialists, those in hospitals, surgical centers, laboratories as well as rehabilitation centers. The Health Information Management professionals in these fields are the practitioners who are charged with the task of creating a medical or health record for each of their patients. Conclusion Records of patients containing their health information are located on numerous entities and in possession of different individuals at varied locations. Managed care plans provide for a network of providers that keeps storage of the healthcare information from different entities, which is only redistributed or rather shared for clinical reasons in the interest of providing optimum care for a patient (Loots and Johnson, 1995). Employers have subsequently been drawn into this pool of data integration for they are to collect and frequently store patient-related information forming part of the employee healthcare benefits’ provision as well as documenting the claims of workers (Cox, 2010). The use of electronic data with the managed care systems has necessitated the development of a link between providers, employers, payers and consumers. Managed systems collect all information from this network to carry out computations regarding healthcare allocation of resources and provision of services. References Anatomy of a physician coder. (2011). Journal of AHIMA. Retrieved Nov. 28, 2012 at . Banthin, J. S., Cunningham, P. & Didem, M. B. (2008). Financial burdens of health care, 2001-2004, Health Affairs, vol.27, no.1, pp.188-195. Cox, T. (2006). Professional caregiver insurance risk: A brief primer for nurse executives and decisionmakers. Nurse Leader, 4(2): pp. 48-51. Cox, T. (2010). Legal and ethical implications of health care provider insurance risk assumption. JONAS Healthcare Law, Ethics and Regulation. 12(4): pp. 106-16. Loots, D., & Johnson M. (1995). Managed care in the Twin Cities and its impact on health information management professionals. Journal of AHIMA, 66(10): pp. 46-8. Sing, Banthin, Selden, Cowan, & Keegan (2006). Reconciling medical expenditure estimates from the MEPS and NHEA, 2002, Health Care Financing Review, vol. 28, no. 1. Trends in Health Care Costs and Spending (2009). Kaiser Family Foundation Health Care Marketplace Project. Retrieved Nov. 28, 2012 at . Read More