University of Southern California Health Insurance and Managed Care Discussion
Please write a discussion and respond to this 2 peers' Discussion PromptsDiscussion:Read about both managed care and fee-for-service health plans. In a short paragraph, discuss the similarities and differences between these plans. Next, respond to the following question: Does managed care give greater accountability for quality of care than fee-for-service? Why or why not? Use at least one specific example in your post.Respond to at least two of your classmates' or instructor's posts. Give your classmates input on the secondary data sources they have chosen. Are there any other funding sources they might consider?ALL citations and references needs to be APA 7th edition format. THANK YOUPeers# 1The term managed care is used to describe a type of health care focused on helping to reduce costs while increasing the quality of healthcare (Cigna,2021). The primary purpose of managed care is to better serve plan members by focusing on prevention and care management, which helps produce better patient outcomes and healthier lives (Fleming,2015). In managed-care plans, the insurance companies contract with groups of providers to offer plan members reduced rates on care and services. These networks can include doctors, specialists, hospitals, labs, and other health care facilities. In managed care, the members are requested to see only those physicians affiliated with the plan. They would need the members to refer from their respective primary care doctors to visit the specialists.Whereas, Under the fee-for-service method, doctors and hospitals get paid for each service they perform. There were no limits on their treatment decisions; doctors or hospitals could order as many tests as they felt necessary (Healthcare.gov, 2021). This method rewards the providers for the volume and quantity of services provided, regardless of the outcome. In this, patients are not benefitted because their insurance companies would often only pay a percentage of the charged fees. The members choose the doctor they want to see and do not need any referral for specialists to visit unless requested by the provider.Over the past few years, the fee for services has changed to value-based payments that reward medical providers based on efficiency and patient outcomes rather than the volume of services provided. Fee for service payment model does not necessarily promote quality (Texas Human and Health Services, 2016). For example, In Managed Care Plan, a periodic check-up by a primary-care physician is paid for by the plan. It may be accompanied by reminders to get regular preventive screening tests, whereas, in fee-for-service, periodic check-ups do not include cancer screening tests like mammograms. Compared to Fee for Service Plans, managed care allows for greater accountability for outcomes and can better support systematic efforts to measure report, and monitor performance, access, and quality. Managed care programs also allow improved care management and care coordination, thereby increasing the quality of care. Peers# 2It is important to note that there is a stark difference in managed care and fee-for-service health care. Additionally, one needs to note that many insurance companies are utilizing a managed cost plan now.A managed care plan is expansive in scope and truly is built to benefit the patient and to ensure that they are receiving proper care (Sekhri, 2000). It is important to note that managed care focuses on the entire healthcare process for the patient. It monitors the patients progression from the PCP to speciality services or hospital services. There is a massive press on health education and preventative medicine. There is a press for the patient to use urgent cares over hospitals whenever possible. Finally, there are incentives offered too providers to ensure that proper, effective, quality care is being delivered (Sekhri, 2000). Finally, managed care functions off of a capitation model. This means that a “fixed amount, on a per-member-per-month” is paid to the healthcare entity (Fleming, 2015). The goal of the healthcare entity is then to ensure that the care rendered for that patient does not exceed the allotted amount, but to also ensure that the patient is receiving quality care.A fee-for-service model is a little different from managed care. Under the fee-for-service scope a provider is paid a Relative Value based unit (RvU) for the care that they render. Essentially, the more RvU’s the provider charges, the more the provider is paid. The quality of care and patient outcomes are not considered in this model. The model allows the providers to manipulate it in a manner that allows greater personal gain.When comparing the two models, a managed care plan holds a higher level of accountability to the provider and the care that is rendered. This is due to the acceptance of risk that the organization has to accept in order to participate. Most of the models are setup in a manner that allow an organization to keep any of the allotted money that is not spent on the patient care. However, if the organization overspends on the patient care, then the organization is responsible for the additional cost and cannot shift the cost to the insurance or patient. This presses the organizations to ensure that they are pressing preventive health medicine and only ordering testing that is truly necessary. Additionally, the organization will need to use high value providers for any services that they refer out in order to continue to contain costs.An example of managed care providing better quality care would be if a patient presented to the hospital with chest pain, dizziness, fever and a plethora of other symptoms. The provider treating the patient would only order the testing necessary to achieve the diagnosis and be able to help the patient. The multi-million dollar work up with extensive imaging would be avoided until it was truly indicated. Once the patient is treated, the organization would assist with ensuring that patient has proper follow-up with any needed specialities and their primary care provider. These extra steps would help to ensure that the patient is not readmitted to the hospital. This is important because hospitals have to maintain a certain re-admittance rate. By performing only necessary testing and care, coordinating the patient’s follow-up and preventing re-admission to the hospital an additional layer of quality and oversight has been added by managed care.
