Managed Health Care

A number of years ago, health care reform was an intense political topic with President Clinton’s proposals to reform medical health insurance. Even though his proposals did not become law, increasing changes are taking place with in the health care system. The goals of these changes are to decrease medical costs, uphold preventive medicine, and encourage primary care. While these changes are positive in many ways, they are also creating concerns between both the health care consumer and the provider. These changes must be managed so that high quality health care is the main interest.

Managed health care plans are the fastest growing type of health care insurance. The fundamental theory of managed health care is to keep the whole community healthy by providing preventive care, such as immunizations and mammograms at little or no cost. The plan keeps costs down by limiting consumer’s access to high-priced specialists and procedures. Since three-fourths of Americans receive their health insurance through their employer, managed health care plans are becoming increasingly more popular with both employees and employers.

In the past, the traditional health insurance plan was the indemnity plan or fee-for-service plan. Patients can visit any doctor at any time and pay directly for their care. After filling out claim forms, they can be reimbursed later, 80 percent of their visit. These plans are less restraining but more costly.

Four types of managed care plans exist. They are the health maintenance organization (HMO), preferred provider organization (PPO), point of service (POS), and independent practice association (IPA).

In an HMO, the member is offered a precise list of doctors and hospitals in which they must receive care in order to be covered. They must also choose a primary care physician in which all care is channeled through. This plan is the cheapest but most limiting. A PPO contracts with physicians and specialists to provide care at discounted rates. Members usually have a wider choice of physicians then in an HMO and do not have to go through a primary care physician. If consumers do not stay with in network, the care is paid for like a fee-for-pay service with about 70 percent of the cost covered. A POS is similar to a PPO in which the patient does not have to go through a primary care physician, but if patients go out of network, it is billed as a fee-for-pay service. An IPA is the fourth managed care health plan in which individual physicians contract with a health plan for a fee or fixed amount per patient.

Managed care offers advantages over traditional pay-for-service plans. Members still pay premiums, usually deducted through their paychecks, but when they visit the doctor, they only have to pay a nominal co-payment fee. Managed care also seeks to control how doctors treat patients to prevent over treatment and escalating costs. Doctor’s credentials also have a tendency to be screened more by managed care companies.

Other advantages are that there are no deductibles to pay, no insurance claim forms to fill out, and by relying heavily on a primary care physician as an overall health care coordinator, managed care gives more comprehensive care to an illness that needs several specialists. In addition, a person has one wellness