MANAGED CARE PROGRAMS

Over the past 50 years, managed care programs have existed such as the Kaiser Permanente Medical Care Program (California) and the Health Insurance Plan of New York City. These programs only affected a minority of patients and physicians, until the past six or seven years during which managed care has grown significantly. Rising costs of health care, particularly in industry, and the fact that approximately 15 percent of the United States population lacks health insurance, have provided stimulus for this growth; health care expenditures account for over 14 percent of the gross domestic product in the United States. Management of medical services is attempted through managed care. It is estimated that around 100 million individuals are now covered by a managed care plan and that 77 percent of employers offer a managed care program (Friedenberg, 1996; Sunshine & Evens, 1994; Quickel, 1996).

It is concluded that through managed care, we may obtain a universal health policy mandated by the states. If congress continues to move Medicaid and Medicare patients into HMOs and industry mandates managed care for employees, this leaves only the medically indigent as a rem

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k patients, excluding coverage for preexisting conditions, and experience rating (Quickel, 1996). Quality Assurance & Improvement These changes have implications regarding quality of services. Radiologists provide an example of future possibilities. Currently, radiologists emphasize good quality at a moderate cost with the elimination of unnecessary procedures. However, the translation of these principles into reality may lead to the emphasis on cost over quality since it is easier to measure cost. Pressures to reduce costs will continue even after savings have been achieved and competition will increase (Sunshine & Evens, 1994). Measures of quality of managed care are mixed; measures include process and outcomes criteria. The quality of care is generally found to be comparable in HMO and fee-for-service settings. Evidence shows that HMO enrollees receive more preventive tests, procedures, and examinations than those in fee-for-service settings; outpatient care satisfaction is rated lower in HMOs. Direct studies of effects of managed care on care provided to diabetics have been done. Capitation, copayments, and deductibles limit the use of services, particularly inpatient hospital care. Payment incentives encourag
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Approximate Word count = 1435
Approximate Pages = 6 (250 words per page)

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