Systems Innovation in Managed Care, Essay Example

Query to the study looks at managed care from provision to consumer from a total channel operations approach. Research design to the study includes organizational analysis of the managed care provider from both consumer and provider perspectives. Interviews were conducted with: 1) a managed care provider; 2) an employer client, represented by an administrative officer responsible for managed care benefits to employees of the company; and 3) a consumer member of a managed care plan. The channel of managed care services is reflected in the discussion of the respondents, and also speaks to a larger field of knowledge sharing aligned with current managed care trends, advantages, and disadvantages to those alternatives.

• 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.

Analysis of the data on the project concerns current trends in the managed care industry. While primary complaints regarding this process were reiterated by the consumer, but 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 were repeatedly mentioned in the discussion of all three of the informants.  In the most extreme cases, patients do not receive what could potentially be life-altering care in a timely and effective manner.

Aside from flow of information, cost to patients was cited as the most prohibitive element of adequate patient care provision, despite efforts by managed care providers and healthcare institutions to reduce out-of-pocket expenses to consumer. Repeatedly discussed was 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). Patient frustration to life-threatening conditions represented the range of effects caused by such errors. 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. Challenges raised by the aforementioned findings to the study indicate that the informatics aspect of managed care must be sharpened to increase comprehensive oversight of managed care services. Without these elements higher levels of quality and patient satisfaction, may not be realized if only limited choices are available to managed care consumers in the process of seeking healthcare provisions that will best suit their needs.

If efficiency in information is directly linked to a ‘duty to a standard of care’ within hospitals and healthcare institutions, Healthcare Management Information Systems (HMIS) offer new promise for enhancement of comprehensive patient care options through “patient-centric management systems,” argue Tan and Payton (2010) in Adaptive Health Management Information Systems: Concepts, Cases, & Practical Applications. Beyond ‘legacy’ systems once designed as unique institutional networks for internal repository of patient record, the new HMIS protocol offer streamlined record keeping environments in consortium with external healthcare, insurance and referral partners, as well as standardization of those earlier systems.

Incorporation of enterprise software based programs into HMIS integrated systems platforms enables hospitals and healthcare institutional partners a range of applications toward advancement of interconnectivity in patient care. Relatively standardized taxonomies of codified data are generated through database repositories such as: Customer Relations Management (CRM); Electronic Health Records (EHR); Enterprise Resource Planning (ERP); and Personal Health Records (PHR) for ‘total’ patient integration (Tan and Payton, 2010). As healthcare institutions move toward greater sustainable growth, managed care must now be integrated into a total chain management system of HMIS operations with the capacity to synthesize the growing consumerism framework (Thompson and Cutler, 24-28).

The link between patient care and financial operations in managed care settings has increased demand for responsive accountability toward mitigation of the growing complications presented to healthcare institutions in partnership with the insurance industry and state Medicaid, as product options such as bundled payments impact the industry (Healthcare Finance News). Comprehensive care now means far more than the pre-existing in-patient scope of services and competitive pressures to supply those services supersedes mere fiscal allocation, amidst conglomerate interests in the healthcare industry (Monegain). Translated in the simplest terms, the complexity of the new managed care model of consumer service presents a strong case for solutions based in HMIS innovation. Sustainable growth means the highest caliber artificial intelligence interface available to physicians, specialists and managed care providers as they seek to curb costs and offer new solutions to better patient care (Pizzi).

Works Cited

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

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

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

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

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

Thompson, Michael and Cutler, Charles M. Health Care Consumerism Movement Takes a Step Forward. Benefits Quarterly, 26.1, 2010, 24-28.