Managed Care Delivery Systems

Managed Care Delivery Systems Introduction: According to Terence Shea in an article published by HR Magazine (2005), in the last fifty years, employers' health cost have soared as coverage has expanded and medical care has been revolutionized. Since the early 1980s, there have been a number of governmental and corporate attempts to slow this dramatic rise in health care expenditures. Most health plans in the U.S. today involve some form of managed care. Nearly 90 percent of Americans with health insurance are covered by HMOs and other managed-care plans. The reason for the shift from the traditional to managed care plans was to hold down healthcare costs. As HMOs grew physicians in private or small group practices have become
less common (Shea, 2005). 1. According to an essay published online by the California Medical Association, an Individual Practice Association (IPA) is a type of Health Maintenance Organization (HMO). The IPA contracts with individual health care practitioners or an association of individual medical doctors and other health care practitioners to provide health care services in return for a fee. IPAs generally include large numbers of individual private practice physicians. The IPA compensates health care providers on a per capita fee, or on some other agreed basis for compensation (Individual Practice Association, 2003). IPA health care providers practice in their own offices and can continue to also see fee for service patients.
An IPA is a legal entity organized and directed by physicians in private practice to negotiate contracts with insurance companies on their behalf. Participating physicians are usually paid on a capitated or modified fee-for-service basis. An IPA can exert influence on be half of its members to counterbalance the leverage of health care insurers. An IPA organizes the delivery of care, negotiates contracts with insurance companies; credentials and inspects member physicians, establishes primary care provider and specialist responsibilities; and disburses payment to
physicians. 2.
According to an essay published online by the United States Department of Health and Human Services, one of the goals of managed care HMOs contracting with IPAs is to prevent the potential overuse of health care specialists. The traditional HMOs permit access to specialists only with authorization from a primary care provider acting as a gatekeeper. According to a recent study, individuals who have direct access to specialists in their HMOs do not make more visits to specialist than individuals enrolled in gatekeeper HMOs. According to this essay, the rules governing the gatekeeper's role in an HMO may actually encourage additional visits to the primary care physician and to specialists. The rational is simple: the more visits one has to a primary care physician, the more opportunities one has to get a referral to a specialist. Thus, the Managed Care IPA model actually strain rather reduce the strain on both primary care services and the visits made to specialists (Health Care Costs and Financing, 2000). 3. According to an essay published online by the National Cancer Institute, transitional care can be defined as that which is required to facilitate a shift from one stage of care to another. For example, as a disease progresses, a patient may require vastly different levels of treatment within increasingly specialized, costly and comprehensive forms of treatment. For an increasing numbers of patients enrolled in HMOs with a goal of showing a profit,
managed care results in challenges in transitioning from routine to specialized health care services (Transitional Care Planning, 2005). Managed Care IPAs tend to try to emphasize disease prevention and health education, eliminate the paperwork, and lower the cost of medical services. Members of managed care plans usually do not have claim forms, and they have few out-of-pocket expenses aside from a monthly premium and small co-payments when services are provided. The medical professionals affiliated with managed-care plans are supposed to ensure that patients receive neither too much nor too little health care. Patients must use the plan's specific network of doctors and hospitals. Many managed care HMOs have systems to review the quality of care provided. These systems are designed to eliminate the unnecessary doctor visits, tests and hospital stays. As mentioned earlier, in many managed care IPA plans the primary care physician plays the role of gatekeeper meaning they are responsible for determining treatment and use of specialists. The primary care physician is responsible for transitioning patients from the first-level to the second level of care in the health care continuum. Each successive level's health care provider is also a gatekeeper striving to control costs while ensuring that patients receive the services they need.

Reference
Health Care Costs and Financing. (2000). Retrieved Jan.. 23, 2006, from Agency for Healthcare Research and Quality Web site: http://www.ahrq.gov/research/feb01/201RA15.htm
Individual Practice Association (IPA). (2003). Retrieved Jan. 24, 2006, from Glossary Web site: http://www.cmanet.org/publicdoc.cfm/61/0/glossary3/76
Shea, T. (2005). Raging Inflation for Health Care Benefits. HR Magazine, 13 (50) , 38-39.
Transitional Care Planning. (2005). Retrieved Jan. 22, 2006, from Cancer Topics Web site:
http://www.cancer.gov/cancertopics/pdq/supportivecare/transitionalcare/HealthProfessional/page