Managed Care Organizations, Term Paper Example


Managed care is a challenging issue for many individuals and organizations due to the complexities of the provisions associated with these plans. Many organizations find these plans difficult to maintain and some are cost prohibitive; therefore, plans with lower amounts of coverage and a higher out of pocket cost for employees and consumers. Furthermore, reimbursements may be difficult to obtain and are often negotiated at lower rates. Also, for many patients, the quality of care declines to the extent that it does not provide any real benefits to patients who require it. When quality of care is compromised in this manner, it becomes difficult to overcome these concerns and to obtain the services that are required to achieve effective care and treatment outcomes.


The consumer-driven healthcare plan supports the ability of consumers to make their own independent decisions regarding their healthcare plans and needs rather than to depend on collective decision-making by other parties (Robinson and Ginsburg, 2009).This type of healthcare practice is resistant to health maintenance organizations (HMOs) and the limitations that these provide to patients in need (Robinson and Ginsburg, 2009). These plans also operate in the context of allowing greater freedom and independence in the context of self-management and improved general wellbeing (Weaver, 2010). In this capacity, healthcare organizations take cues from consumers to facilitate more of a market-driven approach to healthcare and treatment, rather than other types of approaches (Weaver, 2010).

Another perspective of consumer-driven healthcare practice is concierge medicine, whereby “Concierge medicine is a system in which the physician limits the amount of patients in the practice and offers exclusive services for an annual fee. Primary care physicians today are challenged with low reimbursements, malpractice premiums, overwhelming paperwork, and the responsibility of taking on thousands of patients to offset the rising cost of healthcare” (Clark, 2011). Under these conditions, healthcare practice becomes more individualized and enables individuals to have greater freedom in their choices rather than to conform to the needs of managed care and HMO systems (Clark, 2011). This is a challenging practice but it also allows consumers to have the care that they need, but only if they can afford the fees that physicians may charge (Clark, 2011).

Consumer-driven healthcare plans are very different from managed care plans because they reflect a divide between employers and consumers regarding the types of healthcare plans that are preferred (Buchmueller, 2009). Furthermore, these models demonstrate that there are significant challenges associated with the level of health of an individual, as consumer-driven plans often attract persons who are generally healthier (Buchmueller, 2009). However, some experts might argue that consumer-driven plans are not appropriate and may actually deter real quality and progress from being made (Buchmueller, 2009). In support of managed care plans, they represent an assurance that a healthcare provider will be available, even if the provider is not of the best possible quality (Buchmueller, 2009).

Out of pocket costs for managed care versus consumer-driven healthcare plans also play a role in the decision-making process regarding these influences and how they drive healthcare quality and costs over time (Buchmueller, 2009). Typically, when employers pay for part of the premiums for managed care plans, they also limit the number of providers that are available to employees under these plans (Buchmueller, 2009). These findings suggest that there are considerable limitations in managed care service offerings versus other types of plans and the costs may be prohibitive under some plans (Buchmueller, 2009). Nonetheless, it is also evident that the fees associated with many consumer-driven healthcare plans are beyond the scope of affordability for some patients (Buchmueller, 2009). Therefore, in spite of the reduced quality of care for many managed care plans, this is the only feasible option for some individuals and families (Buchmueller, 2009).


The availability of different health insurance plans requires a greater understanding of the differences between these plans and how they impact consumer out of pocket costs. Many organization s choose healthcare plans that have low coverage amounts but are also a lower cost to the organization and to employees. Other plans are more expensive but they are likely to provide greater coverage and provider options. In either case, the quality of care associated with these plans may be suspect and may lead to significant challenges for patients. Therefore, consumer-driven plans have become increasingly common as an opportunity to improve the quality of care, but typically at a higher out of pocket cost.

Both options possess unique challenges for consumers with respect to coverage, quality of care, and reimbursements. Therefore, it is necessary to identify specific resources that will be effective in treating patients with the level of care and treatment that they deserve. It is important for consumers to play a role in making their own healthcare decisions, but to also recognize the limitations of this complex system and how these impact long-term successful outcomes for patients. These elements must demonstrate that the quality of care and treatment is not compromised in the process of offering care and treatment to patients as necessary. This will ensure that patient care is effective in the promotion of successful outcomes for patients over the long term.


Buchmueller, T.C. (2009). Consumer-oriented health care reform strategies: a review of the evidence on managed competition and consumer-directed health insurance.Millbank  Quarterly, 87(4), 820-841.

Clark, P.A., Friedman, J.R., Crosson, D.W., and Fadus, M. (2011). Concierge medicine: medical, legal and ethical perspectives. The Internet Journal of Law, Healthcare and Ethics, 7(1), retrieved from

Hall, M.A., and Schneider, C.E. (2012). Can consumers control health-care costs? Forum for Economics and Policy, 15(3), 23-52.

Robinson, J., and Ginsburg, P.B. (2009). Consumer-driven health care: promise and performance. Health Affairs, 28(2), w272-w281.

Weaver, C.M. (2010). Consumer-driven healthcare: what is it? Journal of Medical Practice Management, 25(5), 263-265.