implement mandatory managed care enrollment without federal waivers W r i t i n g

implement mandatory managed care enrollment without federal waivers W r i t i n g

Please Draft a response to another students discussion Board Post related to managed care. Here is the students post you are replying to:

Managed Care

Growth and Development of Managed Care

What is managed care and where is it going? Managed Care is the supplemental in-between of the payee and the payer according to Essential of the U.S. Health Care System managed care is a mechanism of providing health care services in which a single organization takes on the management of financing insurance, delivery, and payment. (Shi et al., 2019 pp. 206)

1900 – the first protype of managed care was established by railroad, mining, and lumber companies as they employed salaried physicians to provide medical care to workers

1929- Baylor University implemented a predetermined fixed fee per month for its patient

1940’s Permante health plan was created to provide health insurance to industry workers and was later opened to the general public

1973- Health Maintenance Organization Act of 1973 was created due to the increase of Medicaid and Medicare coverages and the overwhelming rise in consumer health needs. The law was designed to provide an alternative to the traditional fee-for-service practice of medicine.

1980’s- Although a slow down in growth of HMO two states California and Minnesota saw a faster growth and private business were increasingly threatened by the erosion of their profits. Consequently, employers started switching from traditional to manage care health insurance

1990’s- Managed care revolution exploded as private employers experienced total increase of 21.7% (Shi et al., 2019)

As the growth of managed care grew new forms were created PPOs used discounted fee payments instead of capitation and other offer enrolled choice of providers who were in their networks. MCO also adopted various methods to control cost such as

Private Insurance Enrollment- although private insurance companies are all consider a form of managed care.

Medicare Enrollment – As one of the early fuelers of managed care now enrollee have the option of choosing a manage care plan under the MA program.

Medicaid Enrollment – With the Balance budget Act of 1997 gave states the authority to implement mandatory managed care enrollment without federal waivers. (Shi et al., 2019) For consumers dissatisfaction with managed care was associated mainly with the erosion of choice resulting from limited number of providers associated with the plans and some restriction in direct access to specialized services. (Shi et al., 2019) In a number of local markets, including many urban health care markets, growth in managed care has manifested itself in the form of multiple (twenty to thirty) competitive network-based managed care plans. In such an environment, individual managed care plans may not hold sufficient market share to influence providers’ behavior. Managed care strategies that focus on modifying providers’ practice patterns must necessarily rely on substantial market share to be successful. The influence of managed care operates at three levels simultaneously. First, each managed care network endeavors to achieve a sufficient share of its contracted providers’ business to conduct profiling, influence individual practice patterns, and adequately convey the plan’s organizational culture to its participating providers. Second, the overall market share held collectively by all managed care plans in a community influences providers’ practice patterns overall (that is, community standards for care). Third, the overall market share held by an individual insurer or managed care plan affects that plan’s ability to recruit physicians whose practice patterns are consistent with the plan’s organizational culture. (Hoy et al., 1991)

Hospitals Role in Continuous Quality Improvement (CQI)

Continuous Quality Improvement (CQI) in Health Care is a structured organizational process that involves physicians and other personnel in planning and implementing ongoing proactive improvements in processes of care to provide quality health care outcomes. (Hosp, 2010) improvement come from the implementation of effective models to improve the business stagey of managing money, care, and patient happiness. Healthcare institutions can choose from several models for CQI, including Six Sigma, Lean, PSDA and the Care Model to implement a CQI framework. Each model is unique, and healthcare organizations should consider where they are in the process of implementing a CQI culture to guide which framework will be most effective for the specific CQI objectives and the organizational culture.

Future of Healthcare

2 Timothy 2:5 An athlete is not crowned unless he competes according to the rules may not sound as a verse that goes along with the theme of our topic but with the many advancement in healthcare being able to bring everything into on neat package should be the goal for one using electronic means in healthcare improves the access of information, next combining stakeholders goals into a package that delivers patient care with uttermost quality followed by business models that keeps the physician nurses in line with the overall model.


Hosp, J. (2010). Continuous quality improvement. Journal of Hospital Medicine, 5(S2), 91–92.

Hoy, E. W., Curtis, R. E., & Rice, T. (1991). Change and Growth in Managed Care. Health Affairs, 10(4), 18–36.

Shi, L., Singh, D. A., & Douglas A. (2019). Managed Care and Integrated Systems. In Essentials of the U.S. health care system (pp. 206–206). Jones & Bartlett Learning.

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