Managed care is the description of various ways that are proposed to reduce the expenditure of providing health care benefits and excelling in the quality of care and these techniques are used by the organizations that provide the people with health care services are called managed care organizations. Managed care organizations help to reduce the health care expenses by giving different kinds of incentives. These incentives can be for the doctors and patients to choose the health care plans that are not so costly and benefits for sharing the expenses of health care and controlling the lengths of stay at the hospital can also be given.The Health Maintenance Organization Act of 1973 further boosted the growth of managed care in the United States that was initiated by health maintenance organizations.
There are four different types of management care organizational plans are mentioned below. Utilization Management Plan This is the assessment of the suitability of medical needs and efficiency in the health care services measures as well as the amenities. These are offered that have to match the requirements of the appropriate health benefits plan.The procedures included in utilization management is the planning that is involved before the discharge and besides other types of plans there are many other processes that utilization management covers that includes concurrent clinical and peer reviews and the requests of the provider, payer or patient are also considered. Purpose of Utilization Management and its Components The purpose of utilization management is to efficiently manage the health care cases.
This has to be taken care of both before and after the services have been rendered. It consists of various processes and these processes are mentioned below.Disease Management A strategy of providing the health care services using interlinked clinical teams that also analyze appropriate data continuously using cost-effective technology is disease management that also facilitates in improving the health care results of patients who have some particular diseases and comprises of self-care management techniques as well as educates the patients, and also provides training. Plans are provided to the patients on individual basis and clinical guidelines. Purpose of Disease Management To reduce the costs involved in health care as well as the quality of life of the people chronic diseases.This is done by preventing or at least reducing the effects of a particular disease.
Elements of Disease Management Business cases are used to classify the economic and health outcome benefits, however, it is important that they are properly verified. CDM structured collaborative are necessary for training and support and teams led by doctors while the participating practices focuses on complete patient care that includes observance to clinical practice guidelines, use of flow sheets and other tools to facilitate planned patient visits and monitoring the performance of the patients is called collaboration.It is essential that the results of the performance of improvement in health of the patients, patient satisfaction, costs and utilization of health services are measured accordingly. For better performance, it is a must for the physicians to augment skills in self-evaluation, patient self-management coaching, and for the use of PDA technology in their practice and also access to the web to manage the flow of information such as having a secure web site for practitioners providing information to help manage the care of their patients.Importance of disease management Significance of disease management is clear from the number of people looking for it due to its benefits for the employer and the employee by saving insurance costs and increasing the productivity of the organization. Quality Assurance Plan This plan is prepared in a methodical way that assures that the variances in processes are clearly identified, reviewed and improvement of the defined processes and also fulfills the requirements of customers and product or service makers.
Structure and processesQuality control and quality assessment are its main elements. Quality control makes sure that the quality is maintained until the product reaches its final stage using some appropriate measures and procedures while quality assessment monitors quality control procedures. It further assesses the quality. Member Services Plan Member of this plan are eligible to obtain the services that the organization has promised.
The member service is related to the managed care organization and its member as they have a contract with insurers or self-insured employers.MCO or the managed care organization is a group of medical service providers such as a group of doctors, clinics, hospitals, pharmacies, etc who work together to take care of their members health needs and provides a wide variety of managed health care services. Types of services that fall into Member Services Plan All MCOs provides the same quality of services to the people who enroll there. The MCOs spends more money on low-cost services such as vaccination and as less as possible on high-cost services such as an open heart surgery.
They advertise heavily and specialize in a variety of types of services based on the type of health plans. Some specialize in low-cost services while others in high-cost services, therefore the people being enrolled in the MCO’s depend on the condition of their health. External Environmental Analysis This helps the pediatric practice become attentive of its influential surroundings to become successful. To understand the external environment where the practice operates, the significant shifts within the external environment must be anticipated.
General issues impact the environment These issues can be primary and secondary.The economic influences lower the employment rate within community that has its mort affect on the poor who cannot afford healthcare services. Political influences of business operating on a small scale in an area and the autonomous views of the community are prevalent within the community while the regulatory influences include any change in the rules and laws.The use of drugs and alcohol affect the social environment as it leads to problems such as low employment and education rate, divorce, single parent homes, gang problems and high population of uninsured or underinsured, etc. nd the technological influences the environment by keeping up with new technologies, procedures, medicines and attitudes towards technology advancements.
Organization Techniques The trend and issue of identification and evaluation are the Medicaid Regulations sometimes threaten the physicians. People who do not have a primary doctor, they can asses to medical care through social services and adolescent birth and high population of uninsured would be an opportunity for them.Control that organizations have with Regulations of Secondary and Primary care Organizations, the ability of secondary providers to refund an acceptable amount, competition and poverty are threats to them. Service Area Competitor Analysis This develops a better understanding of the competitors in the service area, identify vulnerabilities, access the impact of its own strategic actions against specific competitors and identify potential moves that a competitor might make that would endanger the organization’s position in the market. Service Area Profile VariablesThe economic variables are the wide economic distribution, slow economic growth and high unemployment. The demographic variables are the birth rates reaching 75 years, average income around 20,000 for a family of four, even distribution between races, high school education and heavy population of child bearing age and elderly population.
The psychographics variables consist of the medical dependent community upon third party payers, being sociable and youthful. The health status indicators are the mortality rate and infant deaths, etc.The risk indicators are the percentage of alive babies who weigh less than 2,500 grams when they are born, births to the young people as a percentage of live births and the mothers who did not receive any care after giving birth to the baby in first trimester. Competitor The threat of new competitors entering into this service area is not as large as it is in the other service sectors due to the presence of economies of scale, no other healthcare provider need to open a practice for those who are unable to afford care.The bargaining power of suppliers is high in this service sector due to the crucial role that the doctors as they are the ones who control consumer choice.
The threat of substitute products or services is also low as well due to the absence of a variety of substitute services; however the bargaining power of customers is high. Competition is not much due to lack of diversity. Strength and weaknesses highlights the competitive advantage and the success factors of an organization after which it defines its goals.All organizations seek to operate using the least cost while maintaining the efficiency level. Factors critical to success Being in this industry requires a lot of attention and care being given to the patients to ensure proper health care and outcomes with the least costs involved with it, therefore some of the things should be taken into consideration.
And these are its success factors of a managed care industry i. e. ierarchy that is not inherently a problem in the managed care organization, power & power dynamics and interaction, the ability to use skills in a situation, maintaining trust, communicating well and document learning in one area or project such that it can be shared with other areas and projects. Respond of the competitors The strengths and the weaknesses of the competitors should be evaluated to meet the responses well in order to flourish in the industry and stay ahead of the competitors.
There is no danger for the provider unless something unexpected like a merger, acquisition takes place or new competition enters into the healthcare market. Macro issues Three types of trends come under the macro issues i. e. general, societal and industry trends and all of them have to be taken into consideration while forming up a managed care organization. In the general issue, a universal rule is applicable to all managed care organizations, the societal issue includes taking care of the well- being of the society and environment and the industry trends should be followed to cope up with the competitors.
Service areas and competitor issues Mergers between the hospitals, hospital equipment joint ventures and doctor’s provision of information come under the service areas and also include exchange of price and cost data of the hospitals, joint purchasing arrangements among providers, and physician network joint ventures. Competition can be seen in every industry and it is not something that has started happening recently but it is something that has been existing since ages, therefore its is essential for the organization to develop core competencies over other organizations to succeed well.
