Managed Care Organizations

Managed care is a strategy designed to increase efficiency, assure accountability, and promote quality in the financing and delivery of health care. Most managed-care organizations (MCOs) fall into one of three major patterns of organization: (1) staff-model health maintenance organizations (HMOs), which employ salaried providers; (2) network or independent practice associations (IPA), which contract with independent practitioners in private practice; and (3) group practice HMOs, which contract with physician-group practices that devote a substantial percentage of their practice to HMO patients. MCOs actively manage patient care and control or influence the medical treatment decisions of their providers including those health care professionals who are not employed but are under contract to provide services to enrollees according to the terms of a particular health plan (Gold et al. 1995).

HMOs are expected to play a major role in the delivery of preventive services (e.g., screening for disease) for several reasons (CDC 1995a). HMOs are rapidly becoming a major source of health care for most Americans, have historically included preventive services (e.g., screening), are responsible for defined or enrolled populations, and have enthusiastically embraced the recommendations of the USPSTF to define preventive services benefits (Woolf et al. 1996). Moreover, the preventive services measures developed by the National Committee for Quality Assurance (NCQA) to track health plan performance, the Health Plan Employer Data and Information Set (HEDIS), partly were based on the USPSTF recommendations. Specific measures include indicators of plan-specific effectiveness of care with respect to screening for breast cancer, cervical cancer, colorectal cancer, diabetic eye disease, hypertension, and chlamydia (NCQA 1996).

Opportunities. Clinicians, policy-makers, and public health practitioners see an opportunity to strengthen both primary care and public health in the promise of managed care to emphasize preventive services (e.g., screening for disease). To realize those opportunities, effective partnerships must be developed between public health and managed care, and second generation MCOs must strive to meet the standards of accountability for primary care: first contact access, continuity of care, comprehensiveness, coordination, community orientation, cultural sensitivity, and family-centeredness. Many of the first-generation, staff-model HMOs have already made important strides in that direction (CDC 1995a; Starfield 1996).

Challenges. In addition to the issue of accountability for meeting primary care standards, Starfield has identified other challenges associated with minimizing the potential adverse consequences of (1) high levels of cost sharing and enrollee turnover, (2) overreliance on perceived patient satisfaction as an indicator of quality, (3) increasing specialty orientation under the guise of "case management" in certain areas (e.g., mental health), and (4) usurping the traditional role of public health in terms of population-based prevention (Starfield 1996).

Was this article helpful?

0 0
Blood Pressure Health

Blood Pressure Health

Your heart pumps blood throughout your body using a network of tubing called arteries and capillaries which return the blood back to your heart via your veins. Blood pressure is the force of the blood pushing against the walls of your arteries as your heart beats.Learn more...

Get My Free Ebook

Post a comment