Managed Care and Accountable Care Organizations


ManagedCare and Accountable Care Organizations


TheDrawbacks of Managed Care

Managedcare refers to a system of health care whereby patients visitspecified physicians and health centers. There are various types ofmanaged health care plans such as Point of Service (POS), PreferredProvider Organization (PPO), and Managed care in indemnity insuranceplans. Also, there is Private Fee-For-Service (PFFS), IndependentPractice Association (IPA), Health Maintenance Organization (HMO) andManaged Care in a Public Setting (MCPS).The main aim of a managedcare plan is to improve the accessibility of health services to allcitizens at an affordable cost. However, the health care plans havethe following drawbacks

TheDrawbacks of POS

Thedeductibles are often costly even when an individual is visiting anon-network provider (Katz, 2015). Besides, it is even more expensivewhen a person is visiting an out-of-network physician. Furthermore,the premiums paid in the POS cannot be used to consult anout-of-network doctor. Therefore, it might be a waste of money,especially when a patient is required to refer to a specialist who isnot on the POS network. In contrary, most POSs involve consultationswith doctors who are not in the POS system and this forces patient todo a lot of paperwork and incur extra costs.

TheDrawbacks of PPO

ThePPO network requires its clients to fully pay the charges forhealthcare centers and doctors outside the network. Nevertheless, thesystem tries to make it impossible for customers to seek treatmentelsewhere by ensuring that the co-insurance and deductibles arealways high (Katz, 2015).

Thedrawbacks of PFFS

Themain disadvantage of PFFS network is the cost. This system allows itsclients to seek medication from any Medicare or consult a specialistout-of-network without a referral, but at a higher co-payment. As aresult, the network becomes unaffordable to many people (Katz, 2015).

TheDrawbacks of HMO

Inan HMO plan, the deductibles are used to cater for the payment ofdoctors who are on the network only. Therefore, patients are requiredto make a special arrangement whereby they make extra payments whenconsulting a physician out-of-network (Katz, 2015). As a result,members are forced to stick to a primary care doctor. Besides, ifon-network patients seek treatment elsewhere without a referral, thebills are not covered by HMO. Furthermore, the HMO plan is veryrestrictive and the most expensive among all health care plans (Katz,2015). In addition, HMOs tend to offer narrow provider networks so asto mitigate costs. This is a disadvantage since patients may pick aprovider only to notice that the provider is not within his/her area,implying in case of emergencies he/she will need to travel for long.Therefore, HMOs may not be reliable in some instances where emergencycare is required.

TheMajor Features of a Consumer-Driven Health Care Plan (CDHP)

Themain features of a Consumer-Driven Health Care Plan are a personalcare account, a cover that is designed to create a gap between thedollars which are in a client`s account and the point at which adeductible is achieved (DeCenzo et al., 2015). Alternatively, theConsumer-Driven Health Care Plan has designed various internet toolsto enhance better service provisions to patients as well as boostinga friendly consumer involvement. These features help indifferentiating the Consumer-Driven Health Care from other healthcareplans such as Preferred Provider Organization (PPO), Managed Care ina Public Setting (MCPS), and Point of Service (POS) among others. APersonal Care Account (PCA) is vital because it helps individuals tocontrol and manage their medical costs efficiently. Employers usuallydeposit money into an employee`s PCA who can later use the funds topay for doctor`s visits as well as covering any other healthcare thathas been approved (DeCenzo et al., 2015).

TheDifference between a Managed Care Plan, HMO and a CDHP Plan

AHealth Maintenance Organization is a type of a healthcare plan thatis restrictive on the basis of the providers that a patient canconsult (Xiao, 2016). In this regard, individuals with this kind ofinsurance cover are allowed to consult with network physicians.Otherwise, they should cater for their expenses elsewhere, especiallyif they visit out-of-network doctors. The only time that a HealthMaintenance Organization plan allows for an out-of-networkcompensation is during an emergency. On the other hand, theConsumer-Driven Health Care Plan does not restrain on the type ofservice providers that a client should consult (Pagliarulo, 2016).Instead, the plan uses a Personal Care Account (PCA) to ensure thatclients get the best services from providers of their choices. Themoney that is deposited in PCAs can be used widely even in theout-of-network healthcare centers. Besides, the Consumer-DrivenHealth Care Plan covers consultation fees that are used in theout-of-network hospitals. Unlike the HMO, CDHP gives its customersthe freedom to choose the where they want to be treated.

TheConsumer-Driven Health Care plan covers more services than thosecatered for by the Health Maintenance Organization plan (Pagliarulo,2016). Some of the services that are covered by a PCA are lasersurgery, eye exams, dental services, drugs prescription, physicaltherapy, speech therapy among others. The HMO plan mostly includesthe drugs prescription, hospital admissions, emergency rooms visits,and pediatric care.

Thelevel of cost sharing in Consumer-Driven Health Care program isusually higher than in Health Maintenance Organization plan. In theCDHP, cost is shared through a combination of high deductibles andsavings accounts that are tax-advantaged (Pagliarulo, 2016). On theother hand, cost-sharing occurs through co-payments and co-insurance.The CDHP attempts to reduce costs by encouraging their customers toembrace more frugal spending habits. In a co-insurance plan, apatient is expected to pay a portion of his or her hospital bill. Forexample, the HMO plan can decide to pay about eighty percent of thebill and the clients will cover the remaining twenty percent. In casethe charges are about 100 US dollars, the company would pay 80 USdollars while the patient would settle the remaining 20 dollars.

TheFeatures That Enable ACOs to Control Cost and Improve Quality of Care

TheAccountable Care Organizations have the main goal of ensuring thatpatients get services of high quality at the cheapest cost possible(King et al., 2014). The Accountable Care Organizations try tominimize the health care costs by substantially altering the wayhospitals and physicians deliver services. For instance, theAccountable Care Organizations reduce cost by plummeting andpreventing any unnecessary admissions and readmissions to thehospitals. According to the ACO, some admissions are not a must, andthey could be avoided to evade the extra costs. Moreover, theAccountable Care Organizations constrains the health care costs bymaking sure patients visit emergency rooms only when it is a must(Gady et al., 2012). Emergency rooms visits increase the hospitalbills by a significant amount that eventually overburdens thepatients. Furthermore, the ACOs improve the quality of care offeredby physicians through ensuring that the doctors mitigate office-basedcare, as well as employing modern treatment and diagnostictechnologies, in both the hospitals and home care.


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DeCenzo,D. A., Robbins, S. P., &amp Verhulst, S. L. (2015). Fundamentalsof human resource management.Hoboken, NJ: John Wiley &amp Sons, Inc.

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Gady,M., Steinberg, M., &amp Families United for Senior ActionFoundation. (2012). Makingthe most of Accountable Care Organizations (ACOs): What advocatesneed to know.Washington, D.C: Families USA.

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Katz,M. (2015). Healthcaremade easy: Answers to all of your healthcare questions under theaffordable care act.Avon, Massachusetts: Adams Media.

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King,R. C., Rose, R. V., Merritt, M. R., Okray, J., &amp American BarAssociation. (2014). TheABCs of ACOs: A practical handbook on accountable care organizations.Chicago, Illinois: ABA, Health Law Section.

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Pagliarulo,M. A. (2016). Introductionto physical therapy.St. Louis, Missouri: Elsevier.

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Xiao,J. J. (2016). Handbookof Consumer Finance Research.Cham: Springer International Publishing.