Managed care

Definition

Managed care is a healthcare delivery system designed to manage costs, utilization, and quality of care, primarily through a network of providers and a focus on preventive services. It aims to improve patient outcomes while controlling healthcare costs by emphasizing coordinated care, health education, and efficient use of resources.

5 Must Know Facts For Your Next Test

1. Managed care originated in the United States in the 20th century as a response to rising healthcare costs and demand for more organized care delivery.
2. One key feature of managed care is its emphasis on preventive care, which helps reduce the need for expensive treatments by catching health issues early.
3. Managed care organizations negotiate fees with healthcare providers, which can help lower costs for both patients and insurers.
4. There is often a focus on evidence-based practices within managed care to ensure that patients receive appropriate and effective treatments.
5. As the population ages and chronic diseases become more prevalent, managed care plays a crucial role in coordinating complex care needs efficiently.

Review Questions

• How does managed care influence the delivery of primary, secondary, and tertiary care?
  • Managed care significantly shapes the delivery of healthcare across all levels by promoting coordinated services and emphasizing preventive care. In primary care, managed care encourages regular check-ups and screenings to catch health issues early. For secondary and tertiary care, it often requires referrals through primary care physicians to ensure that patients receive appropriate specialist services without unnecessary tests or procedures, ultimately aiming for efficient use of resources.
• Discuss how reimbursement methods like capitation impact managed care systems.
  • Capitation is a reimbursement model where healthcare providers are paid a set amount per patient per month regardless of how many services are provided. This method incentivizes managed care organizations to focus on preventative services and efficient resource utilization, as providers earn the same payment regardless of treatment frequency. As a result, capitation can lead to cost savings for managed care systems while also promoting better patient outcomes by encouraging proactive health management.
• Evaluate the challenges that aging populations present to managed care systems and how these challenges can be addressed.
  • Aging populations often bring complex health needs due to chronic diseases, which can strain managed care systems focused on cost containment. To address these challenges, managed care organizations can implement comprehensive case management strategies that ensure coordination among multiple specialists and facilitate access to necessary resources. Additionally, investing in preventive services tailored to aging individuals can help manage conditions before they escalate, ultimately reducing costs while improving overall patient health outcomes.

Related terms

Health Maintenance Organization (HMO): A type of managed care organization that requires members to choose a primary care physician and obtain referrals for specialist services.

Preferred Provider Organization (PPO): A managed care plan that offers more flexibility in choosing healthcare providers, allowing members to see out-of-network doctors at a higher cost.

Case management: A collaborative process that assesses, plans, implements, and evaluates the options and services required to meet an individual's health needs.