Nursing 108

N108: Transition to the Registered Professional Nurse Role Study Guide of 172 Managed Care Managed care refers to any system for financing and organizing the delivery of healthcare in which costs are contained by controlling the provision of service. A managed care plan may be controlled by the payer (an insurance company), include both payers and providers, or as a business entity that serves only as a go-between. The HMOs always have acted as managed care systems. Many of the current health plans referred to as HMOs are in reality managed care systems that do not focus on health maintenance. In some cases, a group of primary healthcare providers, termed an independent practice association, may contract with a managed care organization to provide services for a preset fee per individual in the program. Managed care organizations also may directly provide healthcare and therefore employ healthcare workers, including nurses. In some managed care organizations, the clients have a choice of care providers and in others may not. Managed care plans that allow an individual the option of going outside of the plan for services that the plan does not or will not provide are called point of service plans . In managed care systems, someone, usually the primary physician, is the gatekeeper. This person monitors and restricts the use of services by the client. The physician sees the client first and then determines whether referral diagnostic services are needed. Many managed care decisions about an individual client are made based on a set of predetermined protocols for treatment. Managed care usually requires that care be authorized or approved for payment before it is provided. Managed care control may extend to such matters as the medications that can be prescribed. A managed care company may have a specific formulary or list of drugs that are allowed to be prescribed. People on Medicare also may have the option of joining managed care plans under an option termed “Medicare Advantage.” Under such circumstances, the person joins the plan and pays a monthly fee similar to the cost of a supplemental health insurance (Medigap) policy. The government makes a single payment for each individual. Medicare recipients pay directly to the plan and the plan provides all of the care. Organizations contracting to provide managed care are expanding their own control through the development of vertically integrated systems , that is, those that provide every level of healthcare service. This system may have contracted physicians, laboratories, hospitals, sub-acute facilities, rehabilitations facilities, and a home care agency. This allows the contracting organizations to offer managed care corporations a package that provides care at all levels for each enrolled member of the managed care plan for a capitated fee. Capitation A fee is paid to a provider organization for each person (each head) signed up for the plan, whether that person uses any healthcare services. Global capitation refers to the inclusion of all services, both inpatient and outpatient, including physician costs in the capitated amount. Capitation shifts an even greater share of the risk of providing costly healthcare from the third-party payer to the provider organization. Providers in a capitated system have an incentive to guide individuals to low cost outpatient services or other care environments rather than the acute care setting. A goal of this payment system is to encourage preventative services that may make high-cost interventions ©2018 Achieve Page 95