Managed Care Payment Systems
Managed Care Payment System: A Critique
Richard Schulz
HCS 521 Health Care Infrastructure
University of Phoenix
Professor Jay Littleton
December 9, 2006
Introduction Individual payments for health care services received have undergone many changes over the past one hundred and fifty years in this country. For many years a fee for service system was in place. This was acceptable at the time because costs were low. However, as costs began to rise, changes in the system occurred as well. Private insurance companies started to form in the 1920s to help consumers afford medical care when needed. Through several evolutions over the years and due to increased costs of medical care, we saw new market oriented public policy initiatives starting to form by the 1980s. In 1970 health care spending represented 7% of the national income, but by 1993 it grew to 13.4% (White, 2004). Health care costs were starting to get out of hand and something needed to be done to address it. "In the public sector, important initiatives included the introduction of the Medicare Prospective Payment System, a range of state reform efforts, and the Clinton administration 's health reform initiative. At the same time, private insurers introduced changes that set in motion a fundamental restructuring of relationships in the health care market place, ultimately giving rise to managed care" (White, 2004). This paper will discuss the rationale, effectiveness, strengths, and weaknesses behind this relatively young reimbursement payment system called managed care. Several reasons explain problems with health care costs. Insured consumers did not have the means or incentives to effectively choose their health care providers and services and this created inflationary distortions in the purchasing system (White, 2004). There was also a lack of provider incentives, a "presence of inappropriate restrictions on payer and provider behavior, including insurance rules and bans on
Richard Schulz
HCS 521 Health Care Infrastructure
University of Phoenix
Professor Jay Littleton
December 9, 2006
Introduction Individual payments for health care services received have undergone many changes over the past one hundred and fifty years in this country. For many years a fee for service system was in place. This was acceptable at the time because costs were low. However, as costs began to rise, changes in the system occurred as well. Private insurance companies started to form in the 1920s to help consumers afford medical care when needed. Through several evolutions over the years and due to increased costs of medical care, we saw new market oriented public policy initiatives starting to form by the 1980s. In 1970 health care spending represented 7% of the national income, but by 1993 it grew to 13.4% (White, 2004). Health care costs were starting to get out of hand and something needed to be done to address it. "In the public sector, important initiatives included the introduction of the Medicare Prospective Payment System, a range of state reform efforts, and the Clinton administration 's health reform initiative. At the same time, private insurers introduced changes that set in motion a fundamental restructuring of relationships in the health care market place, ultimately giving rise to managed care" (White, 2004). This paper will discuss the rationale, effectiveness, strengths, and weaknesses behind this relatively young reimbursement payment system called managed care. Several reasons explain problems with health care costs. Insured consumers did not have the means or incentives to effectively choose their health care providers and services and this created inflationary distortions in the purchasing system (White, 2004). There was also a lack of provider incentives, a "presence of inappropriate restrictions on payer and provider behavior, including insurance rules and bans on
References: Mays, G.P., Hurley, R.E., and Grossman, J.M. (2003). An empty toolbox? Changes in health plan 's approaches for managing costs and care. HSR: Health Services Research 38:1, Part II. February 2003. People 's Medical Society (1997). Managing quality in managed care. People 's Medical Society Newsletter, Vol 16, Issue 5. October 1997. Scanlon, W.J. (1998) Medicare managed care: Payment rates, local fee-for-service spending, and other factors affect plan 's benefit packages. United States General Accounting Office. B-281231. October 9, 1998 White, W.D. (2004). Market forces, competitive strategies, and health care regulation. University of Illinois Law Review Vol 2004 No. 1. April 23, 2004.