Managed care is a method of administering healthcare that has gained significant popularity in the United States. It involves combining the payment and delivery of healthcare services into a single system, with the aim of controlling cost, quality, and access to healthcare for a specific group of health plan enrollees (Scutchfield, Lee, & Patton, 1997). This approach often triggers strong reactions, both positive and negative, from healthcare providers.
One of the main features of managed care is that healthcare providers are paid a fixed amount for treating their patients, regardless of the actual cost of care. This can potentially influence their level of efficiency and the way they deliver healthcare services (Claxton, Rae, Panchal, Damico, & Lundy, 2012). From the perspective of healthcare providers, this payment arrangement can be seen as a constraint on their ability to provide the highest quality care. They may feel pressured to minimize costs and may perceive managed care as a barrier to practicing medicine in the way they deem best for their patients (Sekhri, 2000).
The history of managed care in the United States dates back several decades. It emerged as a response to rising healthcare costs and the need for a more organized approach to healthcare delivery. In the early 20th century, a few pioneering organizations, such as the Ross-Loos Medical Group and the Kaiser Permanente Health Plan, began implementing managed care principles. These organizations focused on integrating the payment and delivery of healthcare services to control costs and improve quality (Sekhri, 2000).
Managed care gained significant traction in the United States during the 1980s and 1990s. The implementation of managed care was driven by employers and private insurance companies seeking ways to control escalating healthcare costs. Health Maintenance Organizations (HMOs) became a prominent form of managed care, with many individuals and families enrolling in these plans to access affordable healthcare. HMOs employed various strategies, such as gatekeeping, utilization management, and capitation, to manage costs and monitor the utilization of healthcare services (Sekhri, 2000).
Since its inception, managed care has evolved and diversified. Preferred Provider Organizations (PPOs) and Point of Service (POS) plans are examples of alternative managed care models that have emerged over time. PPOs offer more flexibility to patients in choosing their healthcare providers but still encourage them to use in-network providers to control costs. POS plans give patients the option to receive care from both in-network and out-of-network providers, but at different levels of out-of-pocket expenses (Sekhri, 2000).
From the perspective of patients, managed care can have both positive and negative implications. On the one hand, managed care can offer more affordable healthcare options and encourage preventive care and disease management. Patients may have access to a network of healthcare providers who are contracted with their managed care organization, resulting in coordinated and comprehensive care. On the other hand, patients may face limitations in terms of choice and access to healthcare providers outside of their network. They may also experience restrictions on certain procedures or treatments deemed unnecessary or of lower priority (Claxton et al., 2012).
In conclusion, managed care has become a popular method of administering healthcare in the United States. It aims to control the cost, quality, and access of healthcare services by combining the payment and delivery into a single system. However, managed care evokes strong reactions from healthcare providers, who may perceive it as a constraint on their ability to provide high-quality care. From the patient perspective, managed care can offer affordability and coordinated care but may also have limitations in terms of choice and access to healthcare providers and treatments. The history of managed care in the United States dates back several decades and has evolved through various models such as HMOs, PPOs, and POS plans.