The current managed care delivery models appeal to be “lean and nimble” for several reasons. At least two models can be used in analyzing the characteristics of such models underlying these managed care delivery models: Preferred Provider Organizations (PPO), and Health Maintenance Organizations (HMO).
In general, these models control the financing and the delivery of certain health services to its members who are enlisted in a certain kind of healthcare plan. The demarcations among the two rest on the model’s distinctive characteristics or features.
The HMO usually enters into arrangements made through contracts with providers of healthcare which, taken altogether, comprise a “provider network.” This makes the managed care delivery model to be “lean and nimble” essentially because it allows members of the scheme to receive medical services at rates that are discounted as a return for being recipients of referrals of health plans.
Moreover, the HMO model entails a Primary Care Physician (PCP) who gives, arranges, authorizes and coordinates each element of the health care needs of the member thus making it a model that is swift in terms of providing managed care delivery.
On the other hand, PPOs are quite parallel to HMOs in the sense that PPOs also engage with healthcare providers such as a dermatologist or a cardiologist in contractual arrangements.
This model grants the members to obtain financial rewards or incentives such as lower co-payments, decreased deductibles, and higher reimbursements just to name a few when they opt to use network providers. With this regard, it can be seen that PPO is a model that is a degree higher to HMOs in terms of being lean and nimble in providing managed care delivery for individuals.
Managed care payers generally compensate primary care providers at rates comparatively lower than specialists. I think this scheme is partially fair and partially unfair for several reasons. These differences can be seen at least fro two points of view: the degree of professionalism required from both specialists and primary care providers and the degree of skills required in performing a certain managed care task.
For the most part, the system where managed care payers generally compensate primary care providers at rates comparatively lower than specialists is partially unfair because the degree of professionalism required from both specialists and primary care providers is essentially similar or has not much of a difference.
The key to understanding this is the fact that both specialists and primary care providers serve the same purpose of providing managed care apart from the fact that the need for managed care from individuals does not relatively vary as to who will provide the manage care since it all boils down to providing the necessary managed care.
On the other hand, the system where managed care payers generally compensate primary care providers at rates comparatively lower than specialists is partially fair because the degree of skills required in performing a certain managed care task justifies the varying compensation between the specialist and the primary care provider.
Since specialists are more learned and are presumed to have more complex knowledge with regard to providing managed care, it is expected that specialists are compensated much higher. Further, it is presumed that there are certain decisions and activities which only the specialist can manage to handle and efficiently perform.
In summary, the issue of fairness between specialists and primary care providers rests on one’s comprehension concerning the similarities and differences between the two.
A quality healthcare is a form of healthcare that effectively and efficiently meets the healthcare necessities of individuals who are in need of one. Hence, if a healthcare is able to effectively and efficiently meet the healthcare necessities of needy individuals, then the healthcare is presumed to be of substantial quality. But what makes a healthcare effective and efficient?
The question of being effective can be answered when a healthcare is able to meet the goals and objectives attached to it. On the other hand, the question of efficiency can be answered when the healthcare scheme is not only able to meet the goals and objectives but, more importantly, meet these things with less obstacles or overcome the hindrances.
In a managed care environment, measuring healthcare can be done in terms of the goals and objectives which are set and ought to be met efficiently and effectively. For instance, in a managed care environment where one of the primary mechanisms is to provide economic incentives in choosing forms of care that cost less, a quality healthcare is one which seeks to promote the health of the patients without putting much burden on them in terms of financial responsibilities.
That is, the cost of the medical care should not be beyond the financial capacities of the patient without compromising the quality of healthcare being served.
More importantly, a quality healthcare is one which has reduced or is devoid of costs that are unnecessary, one which has programs used for reviewing the medical needs in terms of specific healthcare services, has an enlarged beneficiary cost sharing as well as a well-established incentives in terms of cost-sharing for outpatient surgeries. While several types of managed care abound, the varying kinds of restrictions on the variants of managed care should be geared towards promoting a quality healthcare without compromising the financial costs and vice versa.
Alexander, Jeffrey A., and Christy Harris Lemak. “The Effects of Managed Care on Administrative Burden in Outpatient Substance Abuse Treatment Facilities.” Medical Care 35.10 (1997): 1060.
Cawley, John. “The Effect of Managed Care Penetration on Treatment Patterns.” The Journal of Legal Studies 30.2 (2001): 743.