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.

Managed Care Reform Proposal

The American College of Emergency Physicians Foundation describes managed care as “an approach to providing health care that emphasizes wellness and preventive care and seeks to reduce costs by coordinating care through a primary care physician.” Shi and Singh, the authors of Delivering Health Care in America: A Systems Approach, believe that managed care will “remain its central feature” as the US health delivery system continue to undergo changes. Managed care has been a major influence on the delivery of healthcare since 1990. It aims to deliver services that are most appropriate and cost effective while making utilization management its top priority. However, due to its tight regulation and limitations, enrollees have less access to many health care services. Additionally, the difference in quality of care between beneficiaries of managed care and traditional fee-for-service is still in question today.

Although a survey done in New York concluded that enrollees of managed care have higher satisfaction with access and use of health care services compared to those with conventional Medicaid, the extreme odds were the greatest among managed care enrollees. Thus far, studies on quality of managed care have shown little or no significant difference between those enrolled in a managed care plan and those in traditional fee-for-service. With these two matters in mind along with cost, this reform will concentrate on providing individuals with improved access to medical and health care services without increasing cost and with relevant tools, such as quality report cards, to assist individuals choose a health care plan.

Even though managed care expenditures doubled from $27 billion to $61 billion in 2002 to 2007, the spending proportion of all Medicaid spending on services is low compared to about two-thirds of Medicaid beneficiaries. This suggests that many of the highest-cost Medicaid beneficiaries and services are in the fee-for-service sector. Between 1999 and 2008, the expansion of Medicaid beneficiaries in managed care has increased respectively from 51% to 71%. With the changes of this reform, we would imagine that the number of enrollment will rise as more states “now mandate or offer managed care for more complex Medicaid populations, including children and adults with disabilities and chronic illnesses, persons with HIV/AIDS, and ‘dual eligibles’.” Strict standards and procedures have been developed to monitor and assess quality and improvement of managed care and other health care programs. According to the Henry J. Kaiser Family Foundation, nearly 30 states reported that they offer quality report cards to help Medicaid enrollees choose a health plan and quality tend to be higher in provider-owned than other Medicaid dominated plans.

This reform proposal is more important than a competing proposal because it considers three important factors: cost, access and quality. Managed care has been very cost-efficient and will continue to be as access and quality will be improved. Some people may argue that other aspects such as technology or special population may be more important due to current trends and increasing demands of that specific area.

References

"Managed Care Q&A." About Emergencies. American College of Emergency Physicians Foundation, 2011. Web. 28 Feb 2011. http://www.emergencycareforyou.org/YourHealth/AboutEmergencies/Default.aspx?id=26094

"Medicaid and Managed Care: Key Data, Trends, and Issues." (2010) Henry J. Kaiser Family Foundation. Pp. 1-8. http://www.kff.org/medicaid/upload/8046.pdf

Miller, R.H., and H.S. Luft. "DoesManaged Care Lead To Better Or Worse Quality Of Care?" Health Affairs 16.5 (1997): 7-25. Web. 28 Feb 2011. http://content.healthaffairs.org/content/16/5/7.full.pdf+html.

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.

"What is managed health care?" Managed Health Care Plans. American Heart Association, 2011. Web. 28 Feb 2011. http://www.americanheart.org/presenter.jhtml?identifier=4663

Values and Overview of Managed Care

In trying to understand managed care, one has to realize that manage care is not a thing, as Haavi Morreim PhD professor of human values and ethics states “it (managed care) is just a whole lot of different efforts to bring rationality and a bit of fiscal conservation to our health care system.”

Managed care is an approach to delivering and financing health care that is aimed at both improving the quality of care and saving costs. A belief of managed care is that patients are able to receive a high standard quality of care even though there are limited amounts of primary care providers. A second belief of managed care includes limiting waste and abuse by adopting other methods besides a fee-for-service system. In a fee-for-service system providers can incur higher utilization cost by providing more services than are medically necessary. Finally managed care has belief in lowering cost through the use of capitation, discounted fees and salaries. In addition to the three beliefs, manage care as three fundamental values. Three values of managed care include but are not limited to improving quality and saving cost, improving access to care by use of coordinated management of patient’s conditions and finally a focus on primary care relying more heavily on prevention. To improve quality and ensure cost savings, care is rendered by the most appropriate provider and care is rendered in the most appropriate, least-restrictive setting. 

Now that we have discussed the three values and beliefs of managed care, we will talk about the development of managed care.

In essence, the development of managed care can be equated to current employer-sponsored private health insurance. In 1998, 27% of populations with employer sponsored health insurance were managed care, in 2003 the percentage increase to 95%. The types of managed care plans are net-work based manage care systems (or organizations). The three most common managed care organizations include: Health Maintenance Organizations (HMO), Preferred Provider Organizations (PPO) and Point-of-Service (POS) plans. Through these organizations, the health care system has been able to contain costs through choice restriction, gatekeeping, case management, disease management, utilization review, and practice profiling. Although no dollar amount can be reasonably obtained to show transparent cost savings, the savings are found through lower premiums. Although managed care was able to diffuse the high cost of pay-for-service of the 1970s, today’s health care costs have outgrown the current system, making that health care reform is essential, which we will get to at a later date.  When addressing the quality of care Silberman’s article, Managed Care Regulations: Impact on Quality?, notes that states have strict requirements to ensure the quality of care provided through managed care organizations. Internal structures and processes must be included in three areas; internal or external quality assurance systems, utilization review procedures, and dispute resolution mechanisms. In addition to the above mentioned requirements, MCOs have the opportunity to have their quality checked through an accreditation process, which began in 1991.

Managed care encompasses all resources and processes of health care including financing, workforce, special populations, technology, inpatient, outpatient, and long-term care. Technologist might say that it is always important to have funding for their department, because technology is a leading resource that enables us to discover cures and increase the percentage of those who are cured. However, without managed care and without the integration of all the resources necessary to deliver care, the advanced of technology would be meaningless. One could argue that workforce is the most important resource that enables health care to function. In an analogy between health care and the Daytona 500 race, the media often looks at who the driver of the car is and based on their past experience which is most likely to win. Although it’s important to have a well-trained driver, a driver cannot go anywhere unless it has a well build structure (aka a health insurance structure), and the car would represent the system that is managed care.

All in all, because managed care is such a large part of system resources and processes maintaining a health care system that is efficient in cost, proficient in access, and one that continued to reach a standard of quality would be near impossible.   

 -written by Jessica Ramel

Sources Used

Morgan, D.W., Wolfe, P.R., (1991) Can Manage Care control costs? (1991) Health Affairs, 10, no.4, p.120-128. doi: 10.1377/hlthaff.10.4.120

Silberman, P., James, K., Managed Care Regulations: Impact on Quality? (2000), 8(2), p. 21-39 Retrieved from EBSCOhost. http://www.aspenpublishers.com/books/kongstvedt/Readings/Chapter%2035/QMHC%208-2.p21-39.pdf

Shi, L., Singh, D.A., (2008). Delivering Health Care in America: A systems Approach. Sudbury, Massachusetts. Jones and Bartlett Publishers, Inc.

PBS (2010). Managed Care. Retrieved from http://www.pbs.org/healthcarecrisis/managedcare.html