MANAGED CARE AND ACCOUNTABLE CARE ORGANIZATIONS
MANAGEDCARE AND ACCOUNTABLE CARE ORGANIZATIONS
ManagedCare and Accountable Care Organizations.
ManagedCare is a term in the US that is often used to refer to theprocedures that aid in making quality health care services moreaffordable to the citizens (Fisher et al., 2012). Differentorganizations enroll to other agencies that provide such services soas to enable their employees to benefit from the provision ofaffordable and quality healthcare. Some of the types of managed careplans include the Health Management Organization, the PreferredProvider Organization and the Point of Service. All the threeprograms focus on the primary goal of Managed Care, but each has adistinctive feature.
Typesof Managed Care Plans and their Features
TheHealth Management Organization (HMO) allows the registered members toaccess health care services on a prepaid basis. According to Casalinoet al. (2015), individuals in this plan are allowed to access medicalservices at any cost by paying a fixed monthly fee. With the prepayfeature, the Health Management Organizations offer all sorts ofmedical services to its members. The prepaid feature in this plan isreferred to as the premium contribution and is paid at a fixed rateby both the employer and the employee before an employee receives themedical care provided by the plan. The plan, however, expects thatthe members obtain their medical services from the doctors andhealthcare facilities provided by the HMO. The HMO provides acontrolled system where one has to select a first-contact physicianfor all their medical needs (Fisher et al., 2012). It restricts oneto the contact a physician for the provision of general medical careand consultation before taking any alternative step. Again, it coversa broad range of benefits which include hospitalization, surgery,among others, but the employee has no provider choice (Fisher et al.,2012). With such a controlled system, the HMO fee increases at aslower rate compared to other insurance plans.
ThePreferred Provider Organization (PPO) is a managed care plan that,unlike the HMO, does not restrict its members from accessingdifferent physicians or medical care facilities (Casalino et al.,2015). With such unrestricted systems, the members of such a plantend to pay more when they access medical services from the selectedmedical network. Casalino et al. (2015) say that, unlike the HMOwhere the premium contribution is monthly, members of the PPO planhave an annual deductible amount and a co-payment. The plan providesthe member with some healthcare networks to select from, and byobtaining services from the preferred network, they are only liableto pay the copayment for the visit and the annual deductible amount.Here, the cost sharing during service delivery occurs as deductibles,which is a fee that the employee must pay before they enjoy theservices of a healthcare provider. On the other hand, the copaymentsare the payment made by the employee when they receive health careservices. This plan offers members the freedom to choose betweendifferent providers, as suggested by Paul et al., (2014).
Thepoint-of-service plan is another managed care plan, which is providedby the employer. It occurs as a blend of health maintenanceorganization and the preferred provider organization (Fisher et al.,2012). The features of both the Preferred Provider Organization andthe Health Management Organization are fused in this plan. It is madeof a network of healthcare providers where the employee is requiredto choose a primary physician as a primary contact but also gives aprovision of getting health services from outside the network butwith a higher charge. With such a plan, one is not required to pay adeductible and only pays a slight copayment when working with thehealthcare providers within the network. Preferred ProviderOrganization’s plan charges apply when one chooses to obtain carefrom outside the network. In such an instance, one is required to paya deductible and a copayment that includes a certain fraction of thecost incurred during the dispensation of the services (Paul et al.,2014). Such a plan, therefore, allows the employee or member toaccess the benefits of both the HMO and PPO. The Preferred ProviderOrganization plan is more flexible thus giving the employee a fullrange of options depending on their preference, need, and financialability.
PreliminaryResearch on Accountable Care Organizations
AccountableCare Organizations (ACOs) are alliances formed between hospitals andcare providers for the sake of benefiting the patient and thephysicians, as explained by Fisher et al., (2012). They areestablished in different states, and each has their goals andinitiatives Casalino et al. (2015). The Palm Beach Accountable CareOrganization is an example of an ACO, which has made significantadvances in realizing their targets and expanding at an excellentrate. It is located in South Florida and has a total of two hundredand seventy-five participating physicians, and thirty thousandpatients of the Medicare program (Ih-PBC, 2016). The formation of thePalm Beach Accountable Care Organization aimed at using theAccountable Care Organization’s (ACO) principles and ideals toimprove the dispensation of healthcare services to the people ofSouth Florida and reduce the healthcare costs in the region.
ThePalm Beach Accountable Care Organization is run as an IndependentPractice Association. It comprises of doctors who made a decision ofworking together with the aim of providing quality healthcareservices to the people basing on the continuous improvement of worthand focusing on attaining the best outcomes over a prolonged period(Ih-PBC, 2016). The participating physicians laid a strategy for thesuccess of the ACO through diverging from the creation of enormoussetup to focusing on core efforts such as centering on the guidelinesof the Medicare Shared Savings Program. The Palm Beach AccountableCare Organization created an atmosphere for their physicians. Theatmosphere helped them realize that an Accountable Care Model is themost popular tool for the healthcare systems of the modern world. Theorganization’s continued improvement of patients’ healthcaredelivery has earned it an enormous success in the Medicare SharedSavings Program.
Thepayers of this Accountable Care Organization pay through theinsurance providers who liaise with the organization, through acontract (Ih-PBC, 2016). There is also a shared savings program thatenables the providers to co-ordinate and co-operate for the benefitof the patient. Such assists in reducing unnecessary expenses thatmight have been incurred by the patient.
Distributionof payments among the providers in the Palm Beach Accountable CareOrganization is based on a contract signed by the parties involved(Ih-PBC, 2016). After an agreement is reached between the AccountableCare Organization and the insurer, they sign a contract that bindsthem to the agreement. The organization then earns payments which area representation of shared savings that it has attained on medicalspending for a given demographic group. The savings are thendistributed to the member organizations such as the providers, andsome of the money is held for investment purposes. The providers, whoin this case are the physicians, are rewarded with a base salary,productivity incentive, a portion of shared savings and qualitybonus.
Qualityassurance is a fundamental necessity in the provision of healthcareservices, as stated by Shortnell et al., (2010). With such aconsideration, the Palm Beach Accountability Care Organizationemploys the Center for Medicare and Medicaid Services’patients/caregiver experience as a quality measure tool for assessingthe performance of the organization. The device is used to carry outsurveys on patient satisfaction of care achieved by the organization(Shortnell et al., 2010). The tool focuses on aspects such as thetimeliness in the provision of care, communication with theproviders, accessibility to the much-needed services, knowledgesharing, and the patient’s evaluation of healthcare provider (Mora& Walker, 2016). A high-performance rating equates to properpatient satisfaction which gives the organization a higher rank andattracts more clients (Shortell et al., 2010). Poor performance, onthe other hand, diminishes the patients’ trust, which may lead to adiminishing number of members.
Fisher,E. S., Shortell, S. M., Kreindler, S. A., Van Citters, A. D., &Larson, B. K. (2012). A framework for evaluating the formation,implementation, and performance of accountable careorganizations. HealthAffairs, 31(11),2368-2378.
Casalino,L. P., Erb, N., Joshi, M. S., & Shortell, S. M. (2015).Accountable Care Organizations and Population Health Organizations.Journalof Health Politics, Policy, and Law,40(4),821-837. doi:10.1215/03616878-3150074
I-PBC(2016). Palm Beach Accountable Care Organization. Retrieved October10, 2016, from http://www.pbaco.org/
Mora,A. M., & Walker, D. (2016). Quality Improvement Strategies inAccountable Care Organization Hospitals. QualityManagement in Health Care,25(1),8-12. doi:10.1097/qmh.0000000000000081
Shortell,S. M., Casalino, L. P., & Fisher, E. S. (2010). How The CenterFor Medicare And Medicaid Innovation Should Test Accountable CareOrganizations. HealthAffairs,29(7),1293-1298. doi:10.1377/hlthaff.2010.0453
Paul,D. P., Graves, H., Arroyo, D., Neal, K., Daniel, B., & Coustasse,A., (2014, November). Managed care and accountable careorganizations. Northeast Business & Economics Association 2014Forty-First Annual Meeting, West Long Branch, NJ.