Current Trends and Issues in Managed Care

Current Trends and Issues in Managed Care

Current Trends and Issues in Managed Care 150 150 Peter

Current Trends and Issues in Managed Care

Compensation and reimbursement models are another method of controlling access, cost, and quality in a managed care environment. An MCO doesn’t have direct control over physicians or hospitals but through contractual agreements that set incentives for meeting agreed-upon standards, it can exert influence.

This week, you are required to write an essay on the following topics:

Managed care hospital reimbursement
Managed care provider reimbursement
Using the South University Online library (e.g. CINAHL) or the Internet, review at least two articles for each topic and write a review for each source of information. Use the following guidelines for developing your essay:

Write a summary for each topic tying together the information learned about that topic.
Analyze the market forces that would favor using one reimbursement method over another.
Evaluate the key differences between different types of payment methodologies from the provider and hospital point of view.
Evaluate the advantages and disadvantages of the payment methodologies reviewed from the provider and hospital point of view.
Evaluate new payment methodologies resulting from the Patient Protection and Affordable Care Act (PPACA) and discuss future changes in reimbursement methodologies.
Compare and contrast each article to the information discussed in the course textbook.
This paper should be formatted in APA and be 3-5 pages in length without a cover and reference page. Include and introduction and conclusion in your paper.

Sample Paper

Current Trends and Issues in Managed Care

Managed care has impacted the healthcare industry significantly, with the relevant stakeholders having different views depending on how they are affected. Managed care hospital and provider reimbursement have impacted health outcomes and how care is delivered. Major changes resulting in managed care stems from ACA. The purpose of the paper is to identify four sources that address managed care hospital and provider reimbursement. The main points will include a summary for each topic, an analysis of market forces, advantages and disadvantages of payment methodologies, key differences of payment methodologies, and payment methodologies stemming from PPACA.

Managed Care Hospital Reimbursement

Namburi, N., & Tadi, P. (2020). Managed Care Economics. Start Pearls. https://europepmc.org/books/nbk556053

The article acknowledges that the United States has the highest healthcare spending compared to other developed countries. From the hospitals’ point of view, managed care through hospital reimbursement has become a beacon of hope to generate revenue through cost control and utilization management. Managed care through hospital reimbursement is viewed by hospitals as somehow unfair as certain hospitals are punished based on their performance. Managed care through hospital reimbursements has turned out to be cost-effective. For example, in the California state, a slower growth rate of 25% in hospital costs was witnessed after a 20% growth in managed care market share. Cost-effectiveness is the major market force that has fueled the shift towards managed care. The increased demand for quality and safe care has also contributed towards the shift due to the desire to control costs while increasing the number of patients served. Future changes in reimbursement methodologies are expected to focus on the most cost-effective method.

Akinleye, D. D., McNutt, L. A., Lazariu, V., & McLaughlin, C. C. (2019). Correlation Between Hospital Finances and Quality and Safety of Patient Care. PLoS One14(8), e0219124. https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0219124

The article aims at establishing a correlation between the financial position of a hospital and the quality and safety of care provided to patients. The author highlights how managed care through hospital reimbursement can affect the performance of hospitals. The results of the study indicate a relationship between the financial performance of the hospital and the safety and quality performance. The financial performance correlates to total performance scores under CMS value-based purchasing. The results show concern by hospitals on the risk of increasing the gap between hospitals as the financially stable hospital may continue receiving more finances while the conditions of hospitals that are financially unstable deteriorate due to continued penalties. ACA increased the risk by pushing for value-based care and impacting managed care. According to the article, future changes in reimbursement should factor how the financial performance of a hospital impacts ability to deliver quality and safe care.

Managed care Provider Reimbursement

Bowling, B., Newman, D., White, C., Wood, A., & Coustasse, A. (2018). Provider reimbursement following the affordable care act. The health care manager37(2), 129-135. https://journals.lww.com/healthcaremanagerjournal/FullText/2018/04000/Provider_Reimbursement_Following_the_Affordable.5.aspx

The article examines the effects of ACA on provider reimbursement rates and determines the most effective method of delivering healthcare to patients. Managed care through provider payment methods has been utilized as a tool in the attempt to reduce healthcare expenditure. One of the market forces that has favored the use of provider reimbursement is the shift from fee-for-service to value-based reimbursement. This stems from the ACA, which led to Medicaid expansion in various states. Medicaid expansion has been credited with decreased unpaid hospital services. From the provider’s point of view, the transition in the payment system has been challenging but has proven more effective and has made it imperative for physicians to offer high-quality care to patients. From the hospital’s point of view, the change in reimbursement system has been of various benefits especially cost reduction related to preventable occurrences such as readmission rates. Based on the findings of the article, the author concludes that major future reforms in healthcare will focus on increasing quality of care and accountability while decreasing government expenditure on insurance programs. The articles provide real data obtained from hospitals and health care providers reflecting the actual situations as opposed to data obtained in the course textbook.

Gordon, S. H., Gadbois, E. A., Shield, R. R., Vivier, P. M., Ndumele, C. D., & Trivedi, A. N. (2018). Qualitative perspectives of primary care providers who treat Medicaid managed care patients. BMC Health Services Research18(1), 1-8.

https://bmchealthservres.biomedcentral.com/articles/10.1186/s12913-018-3516-9

According to the article, Medicaid managed care has grown significantly, with 77% of Medicaid beneficiaries enrolled in managed care. The study describes the experiences of primary care providers in treating Medicaid patients enrolled in managed care. There is limited research that has focused on the firsthand experiences in providing care to Medicaid beneficiaries. The results indicate that physicians undergo various challenges, including low Medicaid reimbursements and a lack of proper infrastructure to facilitate care coordination. According to the physicians, the ACA increased demand for healthcare while managed care has limited their financial capacity to provide care under managed care programs, especially with a lack of proper efforts to address certain issues such as shortage of healthcare professionals.

Conclusion

            The reviewed articles provide evidence for various issues of managed care discussed in the course textbook. The articles also provide firsthand information about the views of managed care from the perspective of the providers and the hospitals. PPACA has made a significant impact on the shift from fee-for-service to value-based care and reimbursement methods. Both hospitals and providers have positive and negative views about hospital and provider reimbursement. Major market forces include healthcare costs and the increased demand for health care due to increased access to healthcare services. Future trends will focus on cost-effectiveness reimbursement methodologies.

 

References

Akinleye, D. D., McNutt, L. A., Lazariu, V., & McLaughlin, C. C. (2019). Correlation Between Hospital Finances and Quality and Safety of Patient Care. PLoS One14(8), e0219124. https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0219124

Bowling, B., Newman, D., White, C., Wood, A., & Coustasse, A. (2018). Provider reimbursement following the affordable care act. The health care manager37(2), 129-135. https://journals.lww.com/healthcaremanagerjournal/FullText/2018/04000/Provider_Reimbursement_Following_the_Affordable.5.aspx

Gordon, S. H., Gadbois, E. A., Shield, R. R., Vivier, P. M., Ndumele, C. D., & Trivedi, A. N. (2018). Qualitative perspectives of primary care providers who treat Medicaid managed care patients. BMC Health Services Research18(1), 1-8.

https://bmchealthservres.biomedcentral.com/articles/10.1186/s12913-018-3516-9

Namburi, N., & Tadi, P. (2020). Managed Care Economics. Start Pearls. https://europepmc.org/books/nbk556053