Student's View: Managed Care/Health Care Reform

I am a student in the nursing program at the University of Wisconsin-Madison. I feel that providing quality and proper care is one of the top priorities in a health care facility, nursing home, etc. As a nursing student, I think that there should be some kind of an incentive to motivate and enhance the skills and techniques of health care givers/workers as they continue to learn and care for patients. The workload of a nursing student is very heavy and extensive, so I think this would help with burnouts and compassion-fatigue, which is something I noticed that has not come up in managed care.

Also, as a student and a patient, I feel that everyone should get equal access to health care when they need it, but they should not abuse the health care system. Managed care seems like a great approach in addressing this issue, and I like the idea of expanding health insurance to other special populations; however, I think that it is vague and unclear to exactly how managed care is going to acquire the equality part of access to health care. I am aware that not everyone is able to have access to health care for various reasons, but at the same time, those that do have access do not always get the quality of care that they need.

I am for universal health care, and I think that managed care will work hand in hand with it. As I think about my future as an employee/patient, I would want to have the freedom to pick and choose the best managed care plan that would work for me and my family. Also, I would want to pay the least amount of money out of pocket for the services that I use and be able to utilize services at my convience. Overall, I think that managed care offers some flexibility, but this could be improved.

Lastly, I have been taught to be active and involved with my own health care decisions, but as a future nurse, I may face certain situations where a patient may not have the ability to do so. I think it would be a great idea to have supportive and effective programs that provide adequate information and tools for patients, family members and staff when facing difficult/ethically challenged health care situations.

Managed Health Care Reform Proposal

Managed care has drastically changed health care in the U.S. since the ‘90s. It focuses on reducing the cost of health care while increasing wellness and preventative care. According to Shi and Singh managed care organizations offer lower premiums and more comprehensive services than regular insurance companies.

Within managed care there are three major types of organizations. Health Maintenance Organizations, Preferred Provider Organizations and Point-of-Service Plans comprise the three types of managed care organizations. HMOs and PPOs both focus on reducing health care costs through preventative care. HMOs provide medical treatment on a fixed monthly fee. The consumer has a list of medical providers to choose form. The typical advantages of HMOs include low out-of-pocket costs, no lifetime maximum payout, and a focus on wellness and preventative care. Disadvantages include difficulty to receive specialized care, and care from non-HMO providers is not covered. PPOs differ from HMOs because they offer open-panel options for enrollees and offer non-capitation payment. Essentially, consumers choose from a selected panel of physicians and health facilities but also have the option to choose a different health care provider and pay a higher copayment if they desire. Advantages of PPOs include inexpensive out-of-pocket payments and choice of healthcare provider. Disadvantages include less coverage for treatment provided by a non-PPO provider and higher expenses than HMOs. Point-of-Service Plans, also referred to as hybrid plans, combine features of HMOs with those of PPOs. The major benefits of POS include maximum consumer freedom, minimal co-payments, no deductibles, option to use nonparticipating providers (with a substantial fee), and out-of-pocket payments are limited. The disadvantages of POS are the deductibles and co-payments for non-network care and the tight controls to get specialized care.

According to Shi and Singh, in 2006, 20% of employees were enrolled in HMO plans, 60% enrolled in PPO plans and 13% enrolled in POS plans. The government should encourage the usage of POS plans because they give consumers the most freedom with their managed care plans. The increase of POS consumers should begin with the shift of HMO users over to PPO plans since HMO plans are the most tightly constrained. This would then prompt a shift of PPO consumers to POS plans. In the long run this shift would drastically decrease the access of HMO plans. The access of medical providers would remain about the same. Consumers will have more freedom choosing their physician. However, in a study done in Illinois, 97% of physicians in the HMO network were also found in the PPO network. Access to providers in POS plans may increase slightly because of the decrease in HMO plans. Health care costs for enrollees would remain low unless they saw a non-network provider. At the end of the 2010 year, a town in Burlington toyed with removing HMO plans and only offering high deductible health insurance plans. The HMO plans were estimated to increase by 20% in January 2011 which was going to cost the town over two million dollars where as the high deductible plan would cost the town under one million. This realization caused a 12% increase in high deductible plans. Though this situation is slightly different, it shows consumers how costly HMO plans are to the health care system. POS and PPO plans are cost beneficial because consumers get more for what they are paying. In addition, the money put into HMO plans would be shifted over toward the PPO and POS plans reducing the cost for consumers. The quality of health care networks in the POS plans would increase because there would be an increase in access.

Congress should pass a referendum that would support the consumption of more Point-of-Service plans in order to maximize access, reduce cost and slightly increase quality.

References

"Elimination of HMO Illinois plan and Transition to the PPO plan”. 5 Oct 2010. Loyola & You. http://www.luc.edu/hr/pdfs/FAQs.pdf

“HMOs, PPOs, and POS plans”. 25 March 2011. http://www.agencyinf.net/iv/medical/types/hmo-ppo-pos.htm

Shi, L., & Singh, D. A. (2008). Delivering Health Care in America: A Systems Approach (4th ed., pp. 334-371). Sudbury, MA: Jones and Bartlett Publishers.

Warren, C. (2010). Burlington health insurance debate continues. Wicked Local, Retrieved from http://www.wickedlocal.com/burlington/news/x1384149275/Burlington-health-insurance-debate-continues#axzz1HwS8tYSd

Lauren Rush

Managed Health Care-Patient Perspective

Managed Health Care

The company I work for recently began implementation of a new managed health care program. In this program, everyone needed to complete a biometric health screening and an on line personal health assessment questionnaire in order to receive $2,000 to be used for future health care costs (co-pays, deductibles, etc). Each employee then met with a medical technician to discuss the results and develop an action plan to address the areas of concern. This could include stress management, healthy eating, weight loss, quitting smoking, etc.

I found this to be extremely valuable and put personal action plan in place. I had several telephone sessions with a medical professional to discuss how to address stressful situations. I met with a personal trainer who developed a fitness program for me, and I started working out 3 times a week. There have been several “health” challenges/contests to reduce weight or body fat and increase physical activity through the company fitness center that my wife and I have participated in. I feel much stronger and healthier as a result.

The managed health care program has resulted in more out of pocket expenses for myself and family but this is understandable with the rising health care costs. One of the other advantages of the program is the utilization of a patient care hot line where you can call to obtain cost and quality information regarding a physician, clinic, or hospital. This has resulted in cost savings for both me and the company.

I am very happy with the managed care program at my company and would strongly encourage other companies to start one as well.

Managed Health Care Insurance Mandate

In today’s society, it is vital that individuals have health insurance. Health problems are a common occurrence in life, without coverage one’s life saving may be depleted with just one health complication. Managed care is one form of health insurance that can be chosen to reduce the burden of cost. There are three different typed of managed care offered, Health Maintenance Organization (HMOs), Preferred Provider Organizations (PPOs), and Point of Service (POS).

Well these are great options in reducing cost they are not perfect. I feel that the state of Wisconsin should mandate the coverage provided by all types of insurance companies including Managed Care plans. It is predicted that Managed Health Care plans will be the only form of health insurance in the future. However, at this time having so many polices is only causing more work for health care professionals. Having so many polices means having a large variety of paperwork needed to be filed in order to have the service covered by insurance. This seems to cause many problems in filing. It is important that individuals look over their insurance policies closely to see exactly what is covered and what doctors they can see.

All the confusion dealing with the different plans and protocols leads to a large amount of inefficiencies. By having, a mandate on the coverage provides many of these problems be eliminated.

Billing/Insurance. (2010). In Morehead Memorial Hospital. Retrieved April 4, 2011, from https://www.morehead.org/Portal/Main.aspx?mtid=1&tid=300

Common Problems. (2010). In Department of Managed Health Care. Retrieved April 3, 2011, from http://www.hmohelp.ca.gov/dmhc_consumer/pc/pc_problems.aspx

Managed Care. (2011, February 7). In Medline Plus. Retrieved April 5, 2011, from http://www.nlm.nih.gov/medlineplus/managedcare.html

Managed Health Care Planes. (2011). In American Heart Assosiation. Retrieved April 4, 2011, from http://www.americanheart.org/presenter.jhtml?identifier=4663

Shi, L., & Singh, D. A. (2008). Delivering Health Care in America: A Systems Approach (4th ed., pp. 334-371). Sudbury, MA: Jones and Bartlett Publishers

Guest author-A healthcare worker's view

The following post is from my mother, who is currently employed as an diagnostic ultrasound technician.

After being on both sides of the issue; as a patient as well as in a healthcare setting, I can see some problematic areas. As a patient, you want to be well taken care of. With the abundance of information on the internet, people have already pre-diagnosed their condition by the time they see a doctor. They know what tests should be administered and what medications should be prescribed. If a doctor does not agree with their self-diagnosis, they seek out a second opinion, costing more dollars for additional or repeat tests. As a doctor, they are fully aware of the information available to the public. In this day and age of incredulous lawsuits, these doctors feel that every test available must be ordered to cover every aspect of possibilities, including covering themselves, which again adds to the rising costs of healthcare. In the managed healthcare system, if these patients are seeking a second opinion within their network, there should be some sort of information sharing between facilities if they truly are a "network" of their managed care.

I recently had a patient with an interesting concept: If we went back to the way healthcare and insurance used to be, where people basically just purchased "catastrophic" insurance, and paid out of pocket for occasional office visits; you would eventually see a decrease in the cost of doctors' visits due to competitive pricing. Years ago, a doctor's visit was around $30-$50. Today it's not uncommon for a simple "I don't feel good" doctor's visit to be in excess of $200. If you need tests, say for strep throat, what used to be an additional $30-$40 is again, in excess of $200. Clinic visits would get more competitive and lower their prices to keep or attract patients. A lot of unnecessary tests would not be ordered either, if patients were paying out of pocket. Both patients and doctors take advantage of health insurance by ordering and administering too many unnecessary tests.

As a healthcare worker myself, my family's health insurance is over $1,300 per month, 80% of that being paid by my employer. My portion alone is more than we would pay for our occasional doctor's visits, but we keep the insurance for that "catastrophic" occurrence. In addition, being confined to providers within your "network" can have a negative effect. What do you do if you're traveling? The referral is also a scam: If you've had a chronic earache or sore throat, do you really have to spend the time and money seeing your regular doctor so they can refer you to an Ear, Nose and Throat specialist?

As for experience in the healthcare setting, I am somewhat involved in the insurance authorization process. They vary greatly as to what guidelines will qualify a patient for acceptance. They also vary greatly as to the amount they will pay for any particular procedure. For example: if test A costs $2,500, insurance company X might agree to pay $2,000. Insurance company Y might pay $1,500. And insurance company Z might only agree to pay $1,000. If our clinic accepts each of those insurance company's offers, they must write off the excess not covered. However, if Mr. Brown needs that same procedure and is paying cash, his cost is $2,500. Why is that?!?!

Another example of a distorted system is incidental findings: I am an ultrasound tech, and if I am instructed to do an ultrasound on the kidneys, but incidentally as I am scanning see something suspicious in the liver or ovaries, I am not able to fully document or image this finding. It must be relayed to the patient's primary doctor who then needs to order another test or refer the patient to a gynecologist/specialist. In the meantime, if this patient has something critically wrong, valuable time is lost in diagnosis!

Health care may not have been unflawed in the past, but it certainly has not been improved in recent years either. Family doctors are becoming obsolete because everyone specializes in something. There are certainly areas of managed care that need reform, and because managed care is so involved in almost every aspect of care, it is an essential topic to focus on when discussing problematic areas of healthcare.

Medicare Part C and one man's perspective

While searching for a guest author for our team’s managed care blog, I interviewed my grandfather, whose name is Gilbert Meyer. He his 77 years young, and was looking into purchasing a Medicare part C plan also known as Medicare Plus. Below is his experience of working with Medicare.

“My first attempt at acquiring a Medicare plus plan was unsuccessful. I had called my current Medicare provider, and when I contacted them and then they explained that me that I had to go on-line to shop around for a provider. Well for goodness stake. On-line, what they expect me to have access to a computer? I don’t have that kind of access or knowledge to a computer. That is something that you’ll have to look in for me Jessica. I never had any training, heck I didn’t even have type writer training. I remember when I bought your mutter and Susie their first type writer. I didn’t fiddle with that I thought that’s a job for the girls, because I had to get to Gillings to bring food home for everyone.”

When I asked Gilbert when he called the lady from the Medicare office, if he mentioned the fact that he didn’t have access to a computer to the woman. Gilbert responded, “Yea I did. And she told me that I could use one at the public library. But I don’t go to the public library. I have no money for gas to go anywhere. Yea ya know it’s a shame, a guy works hard ya whole life, helping out others along the way, then when you in a bind, and you think your eligible for the trough, ya are working for, then you find out you are not qualified.”

Q: “How would like to see the Medicare program be changed to help improve your quality and care?” A: “I think the care has been good, I can’t complain they’ve always taken good care of me, and by letting ma stay with me to when I had to go to the hospital. They provide damn good care, those nurses know what they are talking about, and they are pretty too.”

Q: “How would you like to see the Medicare changed to improve individual’s access to healthcare?”  A: “it’s hard to cover expenses because there isn’t enough of the check to cover what I need. But it’s also hard to find a place to go that will cover all of our expenses, and still accept Medicare. Ma had heard of Aurora down in Mequon, that would take patients with special needs like me for a lot cheaper, but it’s too much gas money to drive for every cotton thing. That’s why well just stay at the clinic in West Bend. Feel like anybody is good enough to draw a little blood.”

Q: “Do you think that the cost of Medicare Part C needs to be changed?” A: “haha I would always like it to be less but as long as they can still cover my medications so that they wouldn’t be over 70 dollars that would be good.”

Basically during my interview, I found out that my grandfather knew almost nothing about Medicare Plus package. He did not know where to begin with his search, and because of his limited education, and such the fast pace change of society, I feel like he is one of those older adults who is slipping between the cracks in the Medicare system. After I had him come over to my house to look up different providers on the internet, and started asking him about his health. I found out that there were many discounts that he could now qualify for especially in parts B and D of Medicare, which we were both previously unaware of. My hope is that Medicare customer service has an improved education department at many rural and local hospitals because I feel like there is where they can make the most impact to inform patients about the different opportunities they have at saving money, and getting access, without having to give up the quality care that they are receiving now.   

Reform Proposal

Our current establishment of a firm concept of what managed care is also comes with the recognition of flaws within the system. Clearly there are areas in healthcare that need serious reform. This proposal will focus on reorganizing the review process of managed care to include patient feedback and review. The managed care organization should act to implement a system for patient review in order to highlight areas of weakness in the care that patients were given.

Currently, a review system is already in place for analyzing patient treatment after the services have been delivered, which is called Retrospective Utilization Review. This type of review assesses the appropriateness of the care given, but could be improved by adding patient satisfaction surveys to the tools it uses for assessment. While there are already patient review mechanisms placed in some areas of managed care, such as The Consumer Assessment of Health Plans Survey in the Medicaid managed care program, patient review and input not only needs to be further implemented, but the way the surveys are accessed needs to be improved in order to actually lead to improvements in care. They need to be seen not as a threat to physicians and providers as a way to expose certain people who are not doing their job, but instead they need to be formative, guiding change (Lleffe, Wilcock). They can emphasis certain problems, such as the dignity of elderly patients and problems with discharge, so that corrective actions can be taken.
Patient satisfaction surveys can improve cost, access, and quality. Cost can be improved because for one, patient satisfaction leads to a specific organization being made a person’s first choice, and also, by bringing to light problems that, if fixed, would reduce costs. For example, here is a statement from a patient survey response, “Seeing more than one doctor meant the right hand did not know what the left was doing, only my persistent asking got a response and eventually got me a discharge at 7:30 at night” (Lleffe, Wilcock). Clearly this statement shows that because of lack of communication between the physicians the patient had to stay longer than necessary in the hospital, increasing the cost of their stay. This is just one example of ways feedback can improve cost, and this statement also shows how they can improve the quality of care. In general, by having patient feedback you have a collaborative way to measure what types of problems a certain organization has and then find ways to improve upon them. In addition, incentives, possibly through bonuses, can provide rewards to employees of hospitals who are excelling in patient satisfaction. Patient feedback surveys allow for the satisfaction to be measured and reward to be distributed. With a financial reward as an incentive, employees would be more likely to try to improve the patient care, therefore improving quality. And finally, there are ways that patient feedback can improve access. For example, an article discussing the effect of patient feedback at Seton Health St. Mary’s in Troy, NY talked about their experience with patient satisfaction surveys and results(Williams). In one case, after the physicians started doing post-discharge phone calls, there was an immediate impact on the hospitals scores. The hospital recognized this substantial impact, and implemented a program for post-discharge phone calls, therefore improving the access of the patient because it is another source of interaction available to them to improve their health that they might not have otherwise had due to things such as lack of transportation.

The implementation of a patient feedback system is more important than competing topics because if this program can be successfully utilized and the feedback is used it will bring all providers up to a satisfactory level of performance. By doing so, we can provide better access to patients, because as we learned, healthcare is not fully accessible if that care is not adequate. Some people may not feel that this topic is as important as other areas of reform because in a healthcare system whose cost is escalading at such a rate that it will be at 20% of the Gross Domestic Product(GDP) by 2015, ways to contain these costs tend to be at the central focus of healthcare reform. However, with patient review we are able to make sure that the patient’s health is not compromised in order to improve these costs, and after all, saving or improving the quality of the life of the patient will always be the most important thing.



References


"Client Satisfaction Evaluations." World Health Organization. 2000. Web. 27 Mar. 2011.

"Kaiser Commission on Medicaid and the Uninsured." Medicaid and Managed Care:Key Data, Trends, and Issues (2010). Kaiser Family Foundation, Feb. 2010. Web. 27 Mar. 2011.

Lliffe, Steve, Jane Wilcock, Jill Manthorpe, Jo Moriarty, Michelle Cornes, Roger Clough, and Les Bright. "Can Clinicians Benefit from Patient Satisfaction Surveys? Evaluating the NSF for Older People, 2005-2006 -- Lliffe Et Al. 101 (12): 598." JRSM. The Royal Society of Medicine Press, 2008. Web. 27 Mar. 2011.

Shi, Leiyu, and Douglas A. Singh. "Managed Care and Integrated Organizations." Delivering Health Care in America: a Systems Approach. Sudbury, MA: Jones and Bartlett, 2008. 334-71. Print.

Williams, David E. "Hospitals, Physicians Paying More Attention to Patient Feedback." MedCity News. 10 Mar. 2011. Web. 24 Mar. 2011.