Consumers use five attributes to measure the quality of health care services. These include reliability, responsiveness, assurance, empathy, and tangibility of services provided to them (Osborne, 1995, p.3). Any weakness in these five would lead to a compliant…
The patients generally, do not view gatekeeping as favorable and complain that its actual purpose is not to improve the quality of care but to reduce costs that managed care organization incur for providing specialized services to patients (Estes, Rodriguez, 2003, p.383).
The providers working in managed care networks see more patients in a day than other providers. Thus, patients complain that they face huge delays before they are able to see the doctors (Woodard, 2000).
Another concern is the volume of documentation. Multiple pages of forms are required to be filled in by patients detailing personal information. Patients are concerned about access controls to this documentation (Holmes, L., n.d.).
Consolidated Omnibus Budget Reconsolidation Act (COBRA) was passed by United States government in 1986. It is an amendment to the Employee Retirement Income Security Act (ERISA), the Internal Revenue Code, and the Public Health Service Act (US Department of Labor, 2006).
COBRA states that employees, who would otherwise lose their group health coverage due to certain events, would still be able to continue their health coverage. Prior to COBRA, the health care coverage was allowed only up to the time the employee remained in service. In order to be eligible for COBRA continuation coverage, following three requirements must be met:
COBRA is applicable to both private sector and government employers offering group health care plans. But as per the Act's requirements, the company size should be at least 20 employees (including permanent and temporary employees both) on 50% or more business days during the previous year.
Qualifying event refers to the occurrence of an incident that causes the employee to lose the group health plan. The COBRA continuation coverage takes into account the type of qualifying event in determining the beneficiary for continued coverage and the minimum length of the time the coverage should be continued. Following are the qualifying events for employee:
Loss of jobs for reasons other than gross misconduct
Reduction in job hours
Similarly, other qualifying events have been defined by the Act for spouse and or dependents.
This defines the beneficiary who can remain a beneficiary of the health plan even after the qualifying event has occurred. COBRA specifies who can become qualified beneficiary and under what circumstances.
2. Employee Retirement Income Security Act
Employee Retirement Income Security Act (ERISA) was passed in 1974 and "provides a comprehensive federal scheme for the regulation of employee pension and welfare benefit plans offered by employers" (Purcell, Staman, 2008).
Although ERISA regulates the operations of a pension plan and health benefit plan; but it does not mandate employers to provide these plans to their employees.
There are four main parts of ERISA. These include:
Protection of employee benefit rights
This section requires employers to provide employees with the details of their benefit plans; and protects employee benefit rights by disallowing health plan to invest more than 10% in employer's securities.
Internal revenue code provisions
Some amendments were made in the Internal Revenue Code (IRC). The detail of amendments is beyond the scope of this paper.
Jurisdiction, administration, and enforcement
This section ...
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(Nguyen 2009) The different types of managed health care organizations are listed below. The Health Maintenance Organization (HMO): The HMO is indeed considered to be the first among the managed care organization and these organizations grew at a very rapid pace.
These could be by offering economic incentives to physicians and patients to help them choose less expensive forms of care. It also includes choosing programs for assessing and analyzing the medical necessity of specific services; taking advantage of cost sharing; putting a check on inpatient admissions and the duration of stay; and managing high-cost health care cases correctly.
Current paper focuses on the correlation between the policies related to managed care plans and the activities of managers in health services organizations. Emphasis is given on the issue whether these policies can influence the above-mentioned activities and at what level such interaction could be developed.
He/she is also called primary care physician (PCP). The PCP is usually required for the patients who select healthcare officers from the available managed care network plans of hospitals (Department of Health, 2013). Primarily, managed care is a healthcare procedure that covers cost-containment strategies, risk provision among insurance units, employers and providers, administration and reporting thereon.
That is, whether or not the DRG when treated will result in a positive, or a negative outcome. To be more forthright and simple, if the DRG outcome is death, then intervention, those medical resources rendered in the care and treatment of the DRG, should be
The new system was expected to ensure quality care and control over the escalating health care cost. There are various Managed Care models like HMO, PPO, POS, and FFS which offer financing, insurance, delivery and
In addition, public policymakers and administrators identified it as an opportunity to minimize the growing expenditures in Medicare as well as Medicaid programs that have been increasingly inclined towards managed
Notably, there existed a series of controversies related with the system of deciding fee for availing services associated with managed care. More importantly, Medicaid rate setting agencies do not face problem with fixing the base rate of the previous year. However, the
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