Managed care is a popular method of administering healthcare in the United States, which combines the payment and delivery of healthcare into a single system. The purpose of managed care is to control the cost, quality, and access of healthcare services for a specific group of health plan enrollees (Scutchfield, Lee, & Patton, 1997). However, managed care often elicits strong or negative reactions from healthcare providers because they are paid a fixed amount for treating their patients, regardless of the actual cost, which can influence their level of efficiency and may challenge the relationships between doctors and patients (Claxton, Rae, Panchal, Damico, & Lundy, 2012; Sekhri, 2000).
To understand the concept and evolution of managed care in the United States, it is important to explore its history and study some examples. By investigating the perspectives about managed care from the vantage of both healthcare providers and patients, a comprehensive picture can be formed. Some keywords to consider for research include “United States managed care,” “history of managed care,” and “managed care timeline.”
Managed care has a long history in the United States, spanning several decades. It originated in the early 20th century as a response to rising healthcare costs and the need for better coordination of healthcare services. The prepaid group practice model, developed by the Ross-Loos Medical Group in California in the 1930s, is considered one of the first examples of managed care (Scutchfield et al., 1997). This model involved a fixed monthly payment from patients, which covered all necessary medical services provided by the group practice. This approach aimed to control costs and improve access to healthcare services for patients.
Over time, managed care models evolved and expanded across the United States. Health maintenance organizations (HMOs) became popular in the 1970s and 1980s. HMOs focused on preventive care and emphasized primary care physicians as gatekeepers who controlled access to specialists and other healthcare services. The implementation of HMOs was driven by the increasing concern about escalating healthcare costs and the need to manage them more effectively (Scutchfield et al., 1997).
Another major development in managed care was the emergence of preferred provider organizations (PPOs) in the 1980s. PPOs offered more flexibility than HMOs, allowing patients to choose providers within a network and visit specialists without a referral from a primary care physician. PPOs negotiated discounted fees with providers, in exchange for guaranteed patient volume. This approach aimed to control costs through negotiated discounts, while still maintaining some level of choice for patients (Scutchfield et al., 1997).
Despite the various iterations of managed care, it has continued to evoke mixed reactions from healthcare providers and patients. From the perspective of healthcare providers, managed care can pose challenges in terms of financial reimbursement and the autonomy of clinical decision-making. Providers are often paid a fixed amount for treating their patients, which may not accurately reflect the actual cost of care. This can create financial pressures for providers and potentially impact the quality and efficiency of care they deliver (Claxton et al., 2012).
Furthermore, managed care systems may require providers to follow specific protocols and guidelines, which some providers perceive as limiting their clinical judgment and autonomy. This can strain the doctor-patient relationship, as patients may feel that their healthcare decisions are being influenced by financial considerations rather than their best interest (Sekhri, 2000).
From the perspective of patients, managed care can offer advantages and disadvantages as well. On one hand, managed care models can provide cost-effective access to healthcare services, especially for those with limited financial resources. The ability to choose from a network of providers and the emphasis on preventive care can also be beneficial for patients. However, patients may also face limitations on their choice of providers, longer wait times for appointments and procedures, and potential difficulties in accessing specialized care outside of the network (Claxton et al., 2012).
In conclusion, managed care has become a dominant method of administering healthcare in the United States. Its history and evolution can be traced back to early experiments in prepaid group practice models and have since expanded into various models such as HMOs and PPOs. Managed care aims to control the cost, quality, and access of healthcare services for a specific group of health plan enrollees. However, it is a complex system that elicits mixed reactions from healthcare providers and patients. Provider perspective highlights concerns about financial reimbursement and autonomy, while patient perspective weighs the advantages and disadvantages of access and choice. Further research and evaluation are needed to continually refine and improve the managed care system to ensure it meets the needs of both providers and patients.