Sample Healthcare Case Study on Managed Care Organizations

Managed Care Organizations

Disadvantages of a Managed Care

Managed care refers to a health insurance plan that provides quality services and care to those enrolled as members (Health.ny.gov, 2014). One of the criticisms of managed health care is the strictness of SOPs that have to be adhered to. For instance, patients are required to get approval from the insurance provider before they receive any treatment, as well as the kind of treatment and the duration it should take (Csus.ed, 2014). The majority of the patients also claim that it takes too long before they get appointments, and the clinics and offices for network providers are also located in inconvenient places. Others complain that the time allocated for appointments are not usually convenient with their busy schedules. Usually, members do not like the loss of privacy because the managed care company gets detailed information about their medical conditions and treatments (Csus.ed, 2014).

Rules regarding those to be offered services are very rigid. In some instances, some members may not be satisfied with the care they receive from a primary health care physician, and may want to consult another physician, but this is usually not included in the available network. This could only be done by paying the cost in full out of pocket (Insureme.us, 2014).

Features of Consumer Driven Health Care Plan

One of the most significant features of CDHP is that it has a personal care account sometimes referred to as personal spending account. There is a difference in the quantity of money in this account, depending on the type of the account. The account is used by workers to cater for health care charges (Businessgrouphealth.org, 2014). The remaining balance in the account at the end of the contract period is carried forward to the following year if the worker continues to be a member of the plan. If the worker retires, or resigns from the company, but changes his/her health plans, he/she has varied rules with regard to disposition of any remaining balance in the account.

Secondly, CDHP is very flexible with regard to benefit design. The PCA is combined with the traditional high deductible health care coverage that features coinsurance for costs over the deductible and out of pocket limit on costs. This is aimed at protecting a member against monetary effects of a catastrophic health care event.The deductible plan is set to be higher than the amount of dollars deposited in the PCA by the employer (Businessgrouphealth.org, 2014). If a member uses the entire amount in the PCA during the contract period, he/she must incur any other extra expenses for the services offered until the deductible is attained, and then coinsurance takes place.

Thirdly, CDHP depends on the Internet tools to assist workers manage their health care expenses and treatment alternatives. There are three kinds of tools that are popularly found in CDHPs. Firstly, there are tools that assist members to track expenditures in their accounts. These tools are similar to those used in online banking. Those who have enrolled can access through the website of the plan and check expenses charged on the account (Businessgrouphealth.org, 2014). On the other hand, there are tools that assist patients shop for medical care, for example, price lists and comparisons of the qualifications of physicians and performance measures of hospitals.These articles are made available to enrollees through interacting with other Internet health care providers

  1. Compare the difference between a managed care plan (HMO or PPO) and a CDHP plan in terms of choice of providers, covered benefit, and level of cost sharing.

A managed care plan is a health care plan that offers care through a group of physicians and hospitals in a specific location or service areas. The choice of providers depends on a place where one lives or work. One can only qualify to enroll in a HMO plan based on where he/she lives and works. On the other hand, the choice of providers in a CDHP plan is based on a number of approaches provided to their members to control expenses of their health care.

Secondly, HMOs usually restricts out of pocket expenses to relatively low amounts as indicated in benefit brochures. It also offers a wide set of services, but this is when a member use doctors affiliated to HMOs (Health.ny.gov, 2014). It also offers general care to those enrolled with them. However, CDPH enables members to control expenses of their health benefits. The plan also covers health care operating cost up to a specific amount. This implies that members enjoy health care services up to a certain limit stipulated by the plan (Health.ny.gov, 2014).

With respect to cost sharing, HMOs plan offers services to its members, but in case one seeks services from a doctor who is not affiliated to HMO, he/she will be expected to incur extra costs. This is because if an enrollee receives care from a provider who is not incorporated in the plans, the network will not be covered unless it is an urgent situation care. Nevertheless, enrollees in CDPH enjoy freedom of incurring health care dollars up to a certain amount. The enrollee is expected to cost share others after the amount in the account has been used up.

References

Businessgrouphealth.org. (2014). What are Consumer-Driven Health Care Plans? Businessgrouphealth.org. Retrieved on 7 September 2014, from: https://www.businessgrouphealth.org/pub/f315acf5-2354-d714-51ed-8a85aa7ebea0

Csus.ed. (2014). Advantages and Disadvantages.Csus.edu. Retrieved 7 September 2014, from http://www.csus.edu/indiv/h/heflintl/group/section-1/group-5/Website/advantages_and_disadvantages.htm

Health.ny.gov. (2014).Medicaid and Managed Care. Health.ny.gov. Retrieved 7 September 2014, from https://www.health.ny.gov/health_care/managed_care/

Insureme.us. (2014). Life Insurance, Health Insurance and Auto Insurance » Advantages and Disadvantages of Managed Health Care.Insureme.us. Retrieved 7 September 2014, from http://insureme.us/advantages-disadvantages-managed-health-care/

Medicaid.gov. (2014).Managed Care | Medicaid.gov. Medicaid.gov. Retrieved 7 September 2014, from http://www.medicaid.gov/Medicaid-CHIP-Program-Information/By-Topics/Delivery-Systems/Managed-Care/Managed-Care.html