Discuss the following:
1. There are various types of managed care organizations and the common ones are PPO's and HMO's. PPO's are Preferred Provider Organizations and HMO's are Health Maintenance Organizations, the most common HMO in my area is Kaiser. HMO's work differently because the primary care provider works as a gatekeeper to determine if a specialist is necessary for the patient, for treatment or diagnosis. My mom has Kaiser and there are plenty of other hospitals in the area that provide care or have Kaiser doctors available but there is a lack of communication between the two where they don't always have access to her information and that can be frustrating for patients and staff. Does having an HMO such as Kaiser work towards reducing the cost of healthcare? Possibly, there's no real way to compare the insurances with those who are insured because every person has a different level of health and the history is not the same either so you wouldn't exactly be able to those patients are healthier but you can see that those people have access to their primary care doctor who will or will not determine if more testing or access to care is necessary. The HMO plan does serve a purpose in reducing cost by limiting unnecessary appointments with specialists and for those who go for yearly physicals and need visits with specialists that just means that the patient's out of pocket cost is less than if they didn't have an HMO.
Shin, J., & Moon, S. (2007). Do HMO Plans Reduce Health Care Expenditure in the Private Sector?. Economic Inquiry, 45(1), 82-99.
2. People do not see the tight controls of the managed care as a way of cutting costs for the patient, they see it as a way of the health plan making money by not having to spend a lot on care for the patient. Even many doctors feel that the managed care plans limit their ability to provide the care they feel is necessary for the patient.
The Managed care plans try to control the cost of healthcare by having limited list of providers that a person can see, they also require that patients have a regular pcp that they see and have to see them prior to seeing any specialist, the patient also has to have prior authorization for nonemergency procedures, they also review and control how long a patient can stay in the hospital and expensive treatments (Moin, Scales, &Sinay, 2014). Because of these tight controls people believe that the HMO’s makes profits a priority over care (Moin, Scales, &Sinay, 2014). Many people believe that the managed care insist upon the mother leaving the hospital in 24 hours after having given birth and that the doctors time spent with them is decreased due to the managed care (Moin, Scales, &Sinay, 2014). They believe that managed care makes it difficult to see specialists and that they limit medical services to the patient (Moin, Scales, &Sinay, 2014).
Doctors and Hospitals also feel that managed care was dominating them which lead to many mergers and affiliations to gain the larger share of the market and have some leverage to negotiate with the managed care plans (Moin, Scales, &Sinay, 2014).
Directors have “an open-ended duty to maximize the beneficiaries’ wealth,” The Physician has fiduciary duties with respect to specific tasks such as; the duty not to abandon patients, the duty to maintain confidences and to obtain informed consent for treatment (Illingworth, P. (1999). The Fiduciary-based objection to managed care is that it compromises the doctor-patient relationship which may, in turn compromise the quality of care by pitting the physician’s financial interests against the patient’s health interests (Illingworth, P. (1999).
References:
Illingworth, P. (1999). A role for stakeholder ethics in meeting the ethical challenges posed by managed-care organizations. HEC Forum, 11(4), 306-22. Retrieved from
https://search.proquest.com/docview/229305486?accountid=32521
Moin, T., Scales, C., &Sinay, T. (2014). Principles of healthcare quality management: Tools and applications.San Diego, CA: Bridgepoint Education, Inc.