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William Polanco- Rowland–
Please note minimum of 200 words. Please cite one scholarly source. In-text citation should be included.
The cost of healthcare and the associated dollar signs connected to it has kept a certain number of patients away from seeing a doctor when needed. The creation of Managed Care Organizations exists to deal with the exorbitant prices associated with seeing a healthcare provider and actually decreasing costs while increasing the level of care (Nikitas et al, 2020). The common thread is the network of providers that exists within each network that agrees to provide care for the policy holders for an agreed price. Among the Managed Care Organizations are three plans known as Health Maintenance Organization (HMO’s), Preferred Provider Organization(PPO’s), and Point-Of-Service Plan (POS). The structure of HMO’s exists as a network of hospitals, doctors and providers that usually only pay for care in the network visits. These have lower premiums the insured must use a provider within the network that is their Primary Care Physician (PCP). In addition, referrals must be obtained from the PCPs for visits to specialists within the network (healthy.kaiserpermanente.org, 2022) Membership is generally required in the form of employment or one who lives in the area of coverage. With an associated higher cost is the PPO’s. They will allow for visits to in or out of network providers as well as cost of fee coverage for visiting those out of network providers, generally covered by the increased monthly premiums and out of pocket costs (healthy.kaiserpermanente.org, 2022). The third plan being mentioned here is the Point-Of-Service Plan (POS). This is considered a hybrid of plans which allows for the insured to make decisions to see who they want as a provider without first obtaining prior approval. With regard to a plan that works best for the consumer, the HMO plan is one where the nurse within the system is most connected to the providers and the case files allowing for a seamless connection with provider to facility. The other two plans have steps between each provider and information can be lost in the shuffle. The position of nurses working within the healthcare system allows them an opportunity to help keep health costs down via means of self auditing, review of case files and review of the facilities that they are employed at. A nurse can self audit and review the cases they are in charge of and ones they are assigned for audit. They can view the necessity of tests and the frequency of them, sounding the alarm on unneeded exams. They can use their knowledge of billing to review charts to discover errors that might result in costly mistakes to patients and/ or facilities. Lastly, patients can take lessons for nurses in the form of education to learn about proper diet and eating habits, ways to manage lifestyle changes and means to schedule healthcare screenings, to improve long term outcomes.
HMO vs. PPO Plans-What are the Differences? Retrieved Oct 26, 2022, from
https://healthy.kaiserpermanente.org/southern-california/learn/hmo-vs-ppo-advantages
Nickitas, D.M., Middaugh, D.J., & Feeg, V.D. (2020) Policy and politics for nurses and other health professionals: Advocacy and action. Jones and Bartlett Learning. 3rd Edition.
Managed care represents a healthcare system whose main aim is to manage cost, utilize resources and provide quality. Therefore, under the system, there is better efficiency which allows high-quality care delivery at standardized healthcare costs. Various healthcare providers are contracted which may include hospitals, physicians, or nurse practitioners and further provide care to various beneficiaries of the system at reduced costs (Gordon et al., 2018). The healthcare professionals contracted are also responsible for creating the plans of action to ensure the standardization of costs is achieved. Managed programs examples include Health Maintenance Organizations (HMOs) and Point of Services (POS).
Private insurers also play a role in the transformation of healthcare. They primarily include health insurance plans which are not offered by the federal government. The private insurers hence develop various initiatives. One is the value-based purchasing strategy. It is a strategy that is adopted towards basing decisions regarding coverage and payment of policies on the value of treatments and services provided compared with the underlying costs of the treatments (Vlaanderen et al., 2019). Therefore, the healthcare providers are held accountable for both the cost and quality of care provided. Best-performing care providers further receive better compensations and rewards.
The second is pay by performance. It is adopted by private insurers to improve the quality, efficiency, and overall value of health care (Vlaanderen et al., 2019). The performance is measured through the use of noted evidence-based standards Therefore, quality of care is improved among providers with high-performance levels. Moreover, the strategy provides a basis for healthcare providers to improve on their care provision which is also subject to incentives.
Nurses also play various roles to improve quality patient outcomes tied to healthcare reimbursement. First includes increased accountability and responsibility in the areas of transitional care and care coordination (Nickitas et al., 2019). Primarily, the shift from a fee-for-fee service system to a more progressive outcomes-based payment system enhances the need for nurses to take up responsibility and accountability roles towards meeting the needs of the patients. The achievement of improved outcomes provides a basis for accessing better incentives which encourages better effort on their part.
Moreover, nurses may engage in strategies such as reducing wastage towards advocating for healthcare consumers and reduce the increasing cost of healthcare. This is through utilizing resources efficiently where every department remains on budget. The quality of care is therefore enhanced since every resource provided is effectively directed to meeting patient needs in turn reducing the overall cost of healthcare.
References
Gordon, S. H., Gadbois, E. A., Shield, R. R., Vivier, P. M., Ndumele, C. D., & Trivedi, A. N. (2018). Qualitative perspectives of primary care providers who treat Medicaid managed care patients. BMC Health Services Research, 18(1), 1-8.
https://doi.org/10.1186/s12913-018-3516-9
Nickitas, D. M., Middaugh, D. J., & Feeg, M. D. (2019). Policy and politics for nurses and other health professionals: Advocacy and action. (3rd ed.). Jones and Bartlett Publishers.
Vlaanderen, F. P., Tanke, M. A., Bloem, B. R., Faber, M. J., Eijkenaar, F., Schut, F. T., & Jeurissen, P. P. T. (2019). Design and effects of outcome-based payment models in healthcare: A systematic review. The European Journal of Health Economics, 20(2), 217-232.
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