HSA5114 US Health Care System, Florida National University, USA

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Question 1: Introduction: Types and classifications of managed care models.

Answer: Introduction: Healthcare is one of the most important needs in everyone' life, for every individual has to maintain his/her health; and for the purpose s/he pays off the bills. But today, the expenses spent on the treatment of human health have increasedto a large extent; and it has made it difficultfor a common man to afford the bills of doctors.To resolve this issue, the concept of managed care plans was introduced that is a type of health insurance. The non-profit organizations, providing managed care,have contacts or hire healthcare providers,i.e.general physicians, specialist doctors, etc. to provide quality healthcare at low costs for a fixed annual or monthly fee to the people registered with them as members.Over the time managed care has significantly embedded in the US healthcare system. Although it was not evolved on purpose and moreover it is not effective in controlling the cost. In the following lines, an overview of the managed care, it's structure and functioning, and public outcry against it(Ann, 2017).

1.1. Types and Models

As mentioned above the system of managed care hires special doctors, general physicians, and other health providers as salaried employees; and under this system, the patients' access to health providers, clinics, hospitals, and other treatment facilities is controlled.Through this system, health providers or medical facilities receive a fixed amount of monthly or annual salary no matter how many times a patient visits a doctor and be treated.The managed care system is administered under different names, andit is offered primarily by Health Maintenance Organizations (HMOs).Different types of managed care systems includeclosed-panel HMO, open-panel HMO, staff model HMO, group model HMO(Glen, et al., 2017). Due to introduction of this system the ACA assumes that controlling expenditure of healthcare is the joined responsibility of MCOs as well as ACO (Accountable Care Organizations).

In closed-panel HMO, a health maintenance organization pays for the health services provided by the employedphysicians and specialist doctors in its network; while in open-panel HMO, the member or employed health providers are required to participate in a program to see patients who are not registered with any health maintenance organization. In staff model HMO, healthcare providers are hired as salaried employees; while in group model HMO, a health maintenance organization sings contracts with various health facilities. i.e. clinics and hospitals. All these models aim at providing healthcare facilities to the members of the HMOs on reduced costs(Dennis, Manson, Howard, & Hornberger, 2018).

Along with cost control the other objectives of managed care include the accountability of the quality as well as cost, consumer education, health promotion, assessment of health outcomes plus quality and proper management of the health promotion plus disease prevention.

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Question 2: Manage Care Control Cost Plan:

a. Cost savings: ‘‘Structural changes centered around the expansion of managed care have been the major transformative force in health markets in recent years and have played a major role in restraining growth in health spending''

Answer: Cost savings: Usually, patients see a doctor and pay him directly for his services. But it does not happen in the HMO models because there lies no direct connection between the services of the health provider and the fee of the patient.The intention behind avoiding any direct connection between these two things is to keep costs down; because the healthcare is provided by a non-profit health maintenance organization.The HMO models have pursued their apparent benefits regarding cost containment,but researches have shown that an HMO plan does not differ from any non-HMO planbecause the former has achievedno significant cost savings over the latter(Samuel, Li, Matusiak, & Schumock, 2018).Costs are reduced though in the HMO system, but one thing which affects its effectiveness is that patients may increase the utilization of this system. Some critics are of the opinion that the HMOs are no longer non-profit organizations, and they have turned into for-profit organizations because they, under the guise of reduced costs for healthcare, increase the administrative charges.

b. Provider reimbursement: This complaint has two dimensions: hospital profitability, and physician compensation. As far as hospitals are concerned, administrators are worried about profitability or surplus for reinvestment, and consumers are worried about the threat of hospital closures. Few things stir as much public outcry as the prospect of closing a community hospital.

Answer: Provider Reimbursement: As all the healthcare facilities are administered by non-profit organizations under HMOs models, the HMOs have to sign contracts with them for a fixed monthly or annual payment. Because the there lies no connection between the doctor's services and patient's fee, all the affairs are administered by the HMOs; but the problem arises when patients start excessive utilization of the system because they are insured and do not require to pay the doctor. It forces the HMOs to increase its administrative charges to meet the expenses which directly affects its other operations, and it becomes very difficult for the managers of these health maintenance organizations to meet the expenses.Some critics of the HMOs say that the frequent interventions of business managers and the people belonging to fields other than medicine, who continue their struggle to keep the costs low,overturn doctors' decisions(Elliott, et al., 2018).
Moreover, the hospitals whose services are hired by the HMOs their management often become worried about their profits and surplus; because the majority of the hospitals and health facilities registered with the network of the HMOs are from the private sector,and they are for-profit institutions. The excessive utilization of the HMOs system by the consumers causesan increase in the charges of its administrative services, both from doctor and patient, that affects the profits of the hospitals. It also affects the profits of private hospitals listed in the network of the HMOs which they cannot afford; because the decrease in revenues of a for-profit organization affects its functioning because the loss in profits makes a healthcare facility unable to compensate its employees (doctors) which threatens its closure.The closure of a healthcare facility in any town or locality irks the locals; because due to the closure of any such facility,i.e. clinic, hospital, etc. they cannot get healthcare at their doorstep. It leads them to raise their voice on the effectiveness of the system of HMOs; which have gradually turned into a public outcry against the services of HMOs because people are not satisfied with it.

c. Quality of care: Much recent legislation and many legal reforms havebeen aimed at preventing managed care's perceivedquality abuses. The Patient Bill of Rights, which hasbeen heavily debated in Congress, defines, amongother things, the rights of consumers with complexconditions to access directly a qualified specialist,continuity of provider for patients who are underregular treatment, and self-referral to certain types ofspecialists.

Answer: Quality of Care: Recently, serious questions have been raised by people as well as politicians on the effectiveness of the HMOs; as the recent legislation and reforms aimed at preventing the abuses committed under the umbrella of HMOs, who are supposed to provide quality healthcare through employed doctors and other medical specialists on reduced rates.There has been a debate in Congress on The Patient Bill of Rights which doubted the effectiveness of HMOs and raises questions onpatients' direct access to specialist doctors. They have also questioned the complex methods involved in a patient's access to a doctor, and the lack of continuous provision to a patient who is under regular treatment.

One more major problem is insurance does not cover LTC while the private LTC insurance has made limited headway. Although LTC is not only confined to the elderly people as 37% of the consumers are below age 65. It is expected that the people of color have the bad health and they are in genuine need of LTC. Moreover, more than 70% of older American will require LTC. Thus, it is necessary that LTC is integrated with rest of the care system (forbes.com, 2017).

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3. Conclusion: The above discussion can be summed sayingpatients see doctors and pay them for their services which sometimes cost them a lot. To reduce costs, a system was introduced by Health Maintenance Organizations (HMOs) under different models; and according to them, the patients were not required to pay directly to doctors. They were only required to get themselves registered with the HMOs who employed specialist doctors as salaried persons on monthly or annual payment. As there was no direct relation between doctor's services and patient's fee, the costs were kept low. Bu the excessive utilization of this facility by some consumers caused the HMOs to increase administrative charges, both from patient and health provider. This led to the dissatisfaction of people and the private hospitals listed in the HMOs network; the reason behind the hospitals' resentment was the increase in administrative charges by the HMOs caused decrease in their profits; while the people were irked due to increase in administrative charges and the closure of some health facilities at their hometown. This led to a public reaction against the effectiveness of the HMOs; and the matter reached Congress, where ‘The Patient Bill of Rights'for evaluating the performance of HMOs and questions were raised on their functioning. It led to legislation and the enactment of policies which aimed at preventing the alleged abuses and exploitations committed against patients and health facilities.

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