HMO
The system of managed care began in the United States in the early 1900s, in an effort "to provide coordinated health care in a cost-effective way"(Amer. Assoc. of Retired Persons). Until recently," managed care has emerged from the shadows to become the dominant form of health insurance and delivery," succeeding the older fee-for-service program (Zelman and Berenson 2). Today, about 160 million Americans are enrolled in some kind of managed care plan. Managed care "has made health care more affordable andmore accessible for Americans. But sometimes cost cutting can lead to lower standards" (Clinton 1). Because managed care plans provide medical care to their members at a fixed rate, there is a substantial limit to the medical care each member can receive. Under this system of prepayment, managed care organizations (MCOs) can profit off every dollar of revenue that is not directly spent on patient care. This produces the problem of incentives, or temptations for MCOs not to pr!ovide sufficient medical care to their members, all too often resulting in tragedy (Fox, et al. 56). This problem explicitly impacts the estimated 125 million Americans who receive health insurance through MCOs that are provided by t
tage of health care services causing an unbalance in the health care budget. If managed care legislation passes, it would further more encourage employers to drop health coverage. If employers were to be discouraged from providing health insurance, this would force insurance companies to downsize their networks and eventually consumers would "have substantially less choice among available types of coverage" (Arg. Against Liability). Another point that opponents of the Patients' Bill of Rights want to clarify, is the effect that managed care reform will have on the costs of health insurance. Because the health system is so competitive, insurers "cannot afford to absorb the increased cost of expanded liability" (Arg. Against Liability). These costs would be passed on to employers, who also cannot afford to absorb the costs. Unfortunately, these costs are eventually passed on to employees, "either directly or indirectly lowering their pay or decreasing the amount of benefits they! Works Cited Clinton, Bill. "The President's Radio Address." Weekly Compilation of Presidential Documents. 10 August 1998: 1556. "ERISA Managed Care Organizations Should Be Held Accountable for Decisions that Harm Patients." 1 February 1998. (21 April 1999). Fox, Peter D., et al., eds. Determinents of HMO Success. Office of Health Maintenance Organizations. January 1998: 56. Hoffman, Ronald F. and Mark O. Hiepler. "An Easy Out for Managed Care." The Washington Post. 4 April 1998: A19."Managed Care Reform Legislation: Fact vs. Fiction." 1 January 1999. http://www.patientadvocacy.org/main/managed care/mcrl_fvf.html (21 April 1999). "Managed Care: What Consumers Need to Know." 3 August 1998. (21 April 1999). Pollack, Ron. "Current Problems with the Federal Employment Retirement Income Security Act of 1974." 14 May1998. (21 April 1999). Zelman, Walter A. and Robert A. Berenson. The Managed Care Blues and How to Cure Them. Washington D.C.: Georgetown Press, 1998. nformation about treatment options that may not be covered by their health plans" (Cooper). This is a clear violation of the informed consent requirement that Congress has dictated as law. Moreover, gag clauses may also limit physicians from referring patients to specialists outside their health plans. Some managed care organizations and insurance companies retaliate against doctors who send their patients to specialists too many times, or too soon, or order expensive tests that the doctor feel is necessary but the MCO does not. They retaliate by firing doctors who do not follow their rules even if their rules may be dangerous to patients. The pre-determined budget or utilization target that MCOs establish and their physician payment system affix more problems. The system of capitation that physicians are paid accordingly to, provides physicians a fixed amount, not per service, but per enrollee on a monthly basis. Because physicians are given a utilization target that limits h! insurance through their employers. Today, the vast majority of insured Americans acquire their health insurance through the workplace. ERISA governs the employer-based health system to protect employees from the potential abuses from their health plans (Amer. Psych. Assc.). Although both the tax code and ERISA were concocted to help and protect employees, they play an indirect role in shaping the inefficiencies that envelop the employer-based system of health care. Subsequently, regulations imposed by managed care organizations (MCO) on physicians also contribute to the inefficiency. Under today's tax code, Americans can receive a discount on health insurance, granted that they attain it through an employer. The reason for this stems from a single provision of the Internal Revenue Code, "which excludes employer premiums from the employee's taxable income" (Goodman). This means that health benefits provided by insurers are exempted from an individual's earnings, treating them a! file a claim for damages against their
Some common words found in the essay are:
Patient Advocacy, Zelman Berenson, Revenue Code, Franklin Indiana, Bill Rights, Psych Assoc, United Healthcare, Rights MCOs, Security Act, Arg Liability, managed care, health care, health insurance, 21 april, 21 april 1999, april 1999, patients' bill, patients' bill rights, bill rights, health plans, managed care organizations, care system, care organizations, retirement income security, managed care plans,
Approximate Word count = 2868
Approximate Pages = 11 (250 words per page double spaced)
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