A Managed Care Provider, Research Paper Example

For this assignment, I interviewed a managed care provider, an employer that offers a managed care plan to its employees, and a consumer with a managed care plan. Each of these individuals offers a unique perspective regarding the managed care process, and where their role fits into these plans. The following section will summarize these roles and the perspectives that they possess regarding managed care, and how they are aligned with current managed care trends, advantages, and disadvantages regarding this alternative.

• Managed care provider: this role is unique because the individual serves as a facilitator of the managed care process, which does not always reflect positive outcomes for the insured. Nonetheless, the individual described the ability of the insured to gain access to healthcare options, to manage insurance claims, and to consider other challenges that are relevant in this area, such as referrals, timely visits and tests, and other key factors that interfere with the quality of care that exists for many patients.
• Employer that offers managed care: this individual serves as a representative of the benefits department, and answers routine questions regarding the managed care plan of choice that employees possess. This individual possesses knowledge of the cost of managed care from an employer perspective, so he recognizes the value that is given to employees versus the actual cost. His comments focused on these areas moreso than the quality of care that is offered by a managed care organization.
• Consumer with a managed care plan: this individual was very vocal regarding her experiences with managed care, many of which have been negative for a variety of reasons, including referral requirements, claims, waiting time for appointments, and other related concerns. This person believes that the cost of managed care is not excessive, but as a result, the quality is less than stellar in many different ways.

It is necessary to address these concerns and their role in current trends in the managed care industry. The primary complaints regarding this process were reiterated by the consumer, but in many cases, the quality of care continues to decline, while the wait times to see physicians, to obtain referrals, and to obtain the necessary tests are far too excessive. In these cases, many patients do not receive often life-altering care in a timely and efficient manner. Although managed care attempts to reduce the out-of-pocket cost to the consumer, there are many claims that are denied for errors in coding or other reasons, thereby requiring the consumer to appeal the claim through a lengthy process, or to pay for the claim out of pocket. This set of circumstances is not only frustrating for patients, but may lead to life-threatening conditions in many cases. As a result, there are a number of problematic issues to consider with the managed care process as it currently stands, and therefore, consumers are often left with poor and limited choices, as well as unacceptable quality of care. This continues to be a difficult issue to manage from a wide variety of perspectives, and therefore, must be addressed by managed care providers in order to promote higher levels of quality and patient satisfaction. Without these elements and as the cost continues to rise, there are limited choices for consumers to obtain the type of health care that will best suit their needs.