The Managed Care Plan-Nursing Essay Examples

The Managed Care Plan

The Managed care plans constitute healthcare insurance contracts established between healthcare providers and medical facilities to provide care at affordable costs (Woo, 2021). They include Preferred Provider Organizations (PPOs) and Health Maintenance Organizations (HMOs) (The Managed Care Plan).

Strengths

The HMO-managed care plans have significantly reduced the costs of family premiums among insured populations for over 30 years since establishing the HMO Act of 1973 (Falkson & Srinivasan, 2023). Besides, the HMO program ensures the provision of improved quality patient care. Falkson and Srinivasan (2023) observe that the plan ensures that healthcare facilities and professionals are fully accredited. In addition, satisfy the credentials necessary for providing quality care standards (The Managed Care Plan).

Additionally, the plan allows patients to seek care within their networks, making it easy to identify specialists. Moreover, for treating specific health conditions that may not be provided by the primary provider (Shi & Singh, 2022). The HMO has established procedures for on-time referrals, making it ideal for preventing acute health conditions from exacerbating.

Similarly, Ruth and Lennon (2019) explain that the PPO enhances the transfer of patient information electronically to the referred specialist, eliminating time wastage and loss of medical records in cases where patients must carry physical copies of medical records during referral. Kongstvedt (2019) observes that modern healthcare infrastructures like the electronic health records (EHR) system make it easy to share patient medical records electronically. Henceforth, managed care plans are vital in healthcare since they enhance quality patient care (The Managed Care Plan).

Weaknesses

The HMO plans are associated with some shortcomings, which are likely to impede the provision of patient care. For instance, Shi and Singh (2022) illustrate that the use of primary care providers in directing patients’ access to healthcare is risky due to a lack of expertise in providing specialized care. Some chronic conditions require specialized care and expertise, such as caring for patients with heart conditions, which the primary providers may not have, increasing the risk of potential negative health outcomes for patients (Snohomish County Government, 2022) (The Managed Care Plan).

Additionally, HMO and PPO plans make it challenging for patients without insurance coverage to receive appropriate medical care (Snohomish County Government, 2022; Ruth & Lennon, 2019). Therefore, it is not suitable for poor people under managed care since their options are limited, compelling most of them to seek care in emergency departments. Moreover, Ruth and Lennon (2019) argue that referral procedures for advanced levels of care are tiresome and complex among patients enrolled under managed care plans. The procedures are demanding and consume a lot of patients’ time as they must make follow-ups on appointment schedules and file reviews to achieve positive outcomes (The Managed Care Plan).

The Impacts of PPACA-Obama Care on the Managed Care Process

Obamacare coverage penalizes 30-day hospital readmissions, compelling primary providers to offer quality services. This benefits the Medicare and Medicaid programs, including other commercial medical insurance companies, by ensuring that health facilities hire qualified personnel to provide quality care, a core managed care plan mandate (Brown et al., 2021). Obamacare also bolsters the provision of specialized services for in-network care, reducing the potential of patients incurring additional costs seeking out-of-network care. Additionally, it offers quality and affordable services through the Medicare and Medicaid programs, attracting more patients than the expensive commercial insurers (Ercia et al., 2021). This poses serious competition to commercial insurers (The Managed Care Plan).

Consequently, the Obamacare program expanded the publicly funded Medicaid plan, allowing coverage of adults with annual income up to 138% of the Federal poverty level, increasing care affordability among these populations (Ercia, 2021). It also expanded Medicaid eligibility for individuals with low income and who have no dependents, increasing accessibility of health insurance coverage for most low-income earners (Brown et al., 2021). Thus, these expansions satisfy the goal of managed care process in enhancing access to quality and affordable care (The Managed Care Plan).

References

Brown, E. A., White, B. M., Jones, W. J., Gebregziabher, M., & Simpson, K. N. (2021). Measuring the impact of the Affordable Care Act Medicaid expansion on access to primary care using an interrupted time series approach. Health Research Policy and Systems, 19(1), 1-10. https://doi.org/10.1186/s12961-021-00730-0

Ercia, A. (2021). The impact of the Affordable Care Act on patient coverage and access to care: perspectives from FQHC administrators in Arizona, California, and Texas. BMC Health Services Research, 21, 1–9. https://doi.org/10.1186/s12913-021-06961-9

Falkson, S. R. & Srinivasan, V. N. (2023). Health Maintenance Organization. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; https://www.ncbi.nlm.nih.gov/books/NBK554454/

Kongstvedt, P. R. (2019). Health Insurance and Managed Care What They Are and How They Work. United States: Jones & Bartlett Learning, LLC. ISBN: 9781284152098

Ruth, B., & Lennon, J. (2019). Preferred Provider Organization (PPO) Contractual Issues. Leadership and Communication in Dentistry, 23. Wiley-Blackwell. ISBN: 9781119557210

Shi, L. & Singh, D. A. (2022). Essentials of the U.S. Health Care System. United States: Jones & Bartlett Learning. ISBN: 9781284235104

Snohomish County Government (2022). HMO Pros and Cons. https://www.snohomishcountywa.gov/5323/HMO-Pros-Cons

Woo, K. (2021). What Does “Managed Long Term Care Service” Mean in the United States? A Concept Analysis from a Case Manager’s Perspective. Home Health Care Management & Practice, 33(3), 210–216. DOI:10.1177/1084822320969619