Access, Quality, and Cost-Effective Care, Coursework Example

One of the most pressing issues at the forefront of healthcare administration, managed care advocacy constitutes query to the study, and reviews present managed care decision models from the healthcare institution, patient consumer and employer perspective (Thompson and Cutler, 2010). Recent market research studies on the changes in managed care and the diversification of services look at the impact of products such as ‘bundled payments’ and healthcare management information systems (HMIS) in optimization of comprehensive patient care (Healthcare Financial News, 2010). Channel operations in managed care is only half the story however, and how patients come to their health insurance provider(s) is typically dependent upon a limited number of choices, and even when not impinged upon by up front and deductible costs, might find that discretionary costs in certain care units are either prohibitive or undesirable. The foregoing analysis looks at quality measurement play in assessing the performance of health plans and in assessing the impact of price competition.

From the perspective of the healthcare institutional partner, more options and better integration mean a higher degree of efficiency on the provision to consumer continuum. The distinction between the healthcare administrative approach to managed care and that of the insurance provider is of course the discretionary, yet core operational function that managed care occupies in service to patients within healthcare institutions, and the indemnity of the insurance provider that is basically a retail services business (Thompson and Cutler, 2010). For the patient consumer, the experience of selecting an appropriate HMO or PPO provider can be daunting. As most Americans seek this type of provision through their employer as compensatory benefit, with or without employee contribution, and those benefits may be as limited as a single provider option, or extensive as a cafeteria plan whereby employees are offered a number of providers and customer benefit packages to suit their individual needs. Reliance then, is a significant factor to most American’s ‘choice’ of managed care providers, and those choices may or may not be aligned with national and state mandated standards for healthcare.

For professionals in the managed care industry, priority recommendations are demonstrated in public announcement and publication by Managed Care Executive Group (MCEG) a leadership group of U.S. managed care executives. The scope of the MCEG is dominated by the role of government, enhancing collaboration and working on affordability, and to this end are the Group’s annual ‘Top 10’ industry issues in 2010, illustrated in Table 1.

Table 1

Table 1: ‘Top Ten’ industry issues in managed care, 2010 (MCEG, 2010).

Current trends in research on the managed care industry address primary complaints regarding the impact of healthcare reform, HIPAA requirements to data processing, and integration into medical provider networks. Process implications reiterated by consumer confidence point to the dangers of the devolution of quality of care in the face of a range of factors related to access and efficiency – such as wait time to see physicians, referrals, and to obtain necessary testing. In the most extreme cases, mishandled managed care systems may result in patients not receiving what could potentially be life-altering care in a timely and effective manner.

Aside from flow of information, cost to patients is cited as the most prohibitive element of adequate patient care provision, and this is in spite of efforts by managed care providers and healthcare institutions to reduce out-of-pocket expenses to consumer. Repeatedly discussed are the prevalence of claims denied for errors in coding or related inefficiency reasons of inefficiency; thereby requiring the consumer to appeal the claim through a lengthy process, or provide direct payment for the claim (Healthcare Finance News).

As mentioned, there are a number of problematic issues to consider with the managed care process as it currently stands, with the worst case scenario being unacceptable quality of care. From patient frustration over billing to life-threatening conditions not sufficiently responded to because of confusion within a providers interface with the clinical institution’s healthcare informatics (HI) database, the range of effects caused by such errors has repositioned managed care as perhapsthe priority discussion in policy reform. Healthcare institutions are of course responsive to this, as their accounts receivables are largely dependent upon the revenue insurance policies provide, and changes to channel operations within hospitals and clinical referral institutions within those managed care networks allocating exceptional expenditure for better integration of managed care operations toward long-term solution.

Without higher levels of quality in managed care and attendant patient satisfaction, sustainable growth of healthcare institutions will suffer. They stand to benefit, however, by sharpening investment in administrative informatics. Ultimately, however, comprehensive oversight of managed care services may not be realized if only limited choices are available to patient-consumers seeking healthcare provisions that will best suit their needs.

Government advocacy agencies work toward the possibility of adequate constituent coverage as well, and despite the broad range of privatized service provision in medicine, an example of how governmental agencies index ratings on managed care providers is illustrated in the State of California Office of the Patient Advocate annual HMO Report Card for the City of Los Angeles, 2010 in Table 1.

Opponents of state mandated healthcare question the value of such indexes as the OPA Report Card, and criticize the legitimacy of government opinion in the area of corporate HMO and PPO policy, arguing that nowhere else would consumers find this kind of rating system under the pretense to affect choice in commerce. Proponents argue conversely, that the HMO/PPO industry serves as function within the web of healthcare relationships that consumers engage, and that the high prevalence of errors within the current healthcare industry-insurance industry matrix has evolved to a stage where such publically ranked evaluation is warranted.  Like other fields where there is a high degree of risk involved, and that includes both financial and health risks, the seriousness of the relationship instigates the presence of external regulation, and one only has to look to malpractice cases where ‘a duty to a reasonable standard of care’ has involved joint and several liability of all responsible parties toward settlement of consumer-patient suits.

Conclusion

In the last decade, the link between patient care and financial operations in managed care settings has increased the demand for responsive accountability. Capacity building means synthesis of the growing consumerism framework incumbent to healthcare partnerships in the insurance industry. State Medicaid services also continue to change as product options to patient-consumers expand in some areas, and contract in others over time (Healthcare Finance News, 2010). Now more than ever, the impact of the ‘comprehensive care’ model finds resource in a broadening scope of services, and with this trend, a vision of competitive provision of services (Monegain, 2010). As institutions seek to find new solutions to patient access and better options for curbing costs, efficiency in information has become directly linked to a ‘duty to a standard of care’ within hospitals and healthcare institutions (Pizzi, 2010).

As healthcare institutions move toward deeper integration with managed care providers, consumer serve as a core equity asset in the total chain management system of HMIS operations; offering new promise for enhancement of comprehensive patient care options through “patient-centric management systems” (Tan and Payton, 2010. In review of managed care providers, with costs and provisions, prioritization in selection of individual plans now includes informatics based criteria, like independent ID access to the healthcare institution’s account, medical network of referral providers, outpatient aftercare resources, and wellness education research and other knowledge sharing resources.

Works Cited

Blue Shield of California extends contract for MedeAnalytics’ claims transparency solution (2010). Healthcare Finance News, February 12, 2010.

Monegain, B. (2010). N.C. health system to launch bundled payment pilot. Healthcare Finance News, 22 June 2010.

Pizzi, R. (2010). Actuarial survey says transparency would reduce healthcare costs. Healthcare Finance News, 29 July 2010.

(2010). Study outlines $3.6T in potential healthcare waste reductions. Healthcare Finance News, 14 June 2010.

(2010). Executives group names top 10 challenges for managed care in 2010. Healthcare Finance News, 12 April, 2010. Retrieved from: http://www.healthcarefinancenews.com/news/executives-group-names-top-10-challenges-managed-care-2010

HMO Ratings at a Glance (2010). State of California Office of the Patient Advocate. Retrieved from: http://www.opa.ca.gov/report_card/hmorating.aspx

Tan, J. and Payton, F.C. (2010). Adaptive Health Management Information Systems: Concepts, Cases, & Practical Applications, Third Edition. Sudbury, MA: Jones & Bartlett Learning.

Thompson, M. and Cutler, C.M. (2010). Health Care Consumerism Movement Takes a Step Forward. Benefits Quarterly, 26 (1), 24-28.