Managed Care Plans Analyze How the Policies Essay

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Managed Care Plans

Analyze how the policies and practices related to Managed Care Plans can influence the activities of managers in health services organizations.

Over the last several years, the role of health care organizations has been continually evolving. Part of the reason for this, is because costs have been rising exponentially. Evidence of this can be seen with a survey that was conducted by the Kaiser Foundation. They determined that over the course of one year, health insurance premiums have increased by 14%. This is a part of a larger effort, to deal with rising costs at a variety of health care organizations. (Ableson, 2010)

As a result, a shift has occurred in the kinds of services that are being provided to consumers. This has lead to a transformation in the policies and procedures at managed care plans. To fully comprehend how these shifts are occurring requires examining: the different ways they can have an impact on activities of managers of health services organizations (HSO's). This will be accomplished by: defining managed care, looking at why no single definition can apply, analyzing five major participants, studying how participants can influence managers and discussing the way these concepts can be used in an interview with an HSO manager. Together, these different elements will provide the greatest insight as to the overall influences of managed care plans on the activities of HSOs.

Define Managed Care

Managed care is when you are controlling the costs associated with the delivery of health care services through the primary care doctor. They are known as the gatekeeper, who will only refer patients to those services that are the most expensive, when they are absolutely necessary. To include: the use of specialists, physical therapy and various types of surgery. ("Definition Managed Care," 2011) This is important, because it is showing how managed care organizations are focused on increasing their profit margins and reducing costs as much possible.

Explain why there is no one single definition that accurately describes all forms of Managed Care.

The reason why, there is no single definition is because once you move beyond the basic description, the kinds of services and organizations are different. This is due to the fact that many will sub-divide based upon the treatment options they are providing. A few of the most notable include: HSOs, preferred provider organizations and point of service organizations just to name a few. This is significant, because it is illustrating why, there is no single definition that can be applied to managed care. As the areas of specialization and the kinds of customers that they are serving will vary from: one entity to the next. (Duncan, 1997, pp. 24 -- 30)

Analyze the 5 major participants that are involved in each Managed Care arrangement.

The five major participants that are involved in the managed care arrangement include: the patient, the health care provider, the managed care organization, regulators and shareholders. The patients are paying the premiums into the plan. Their objectives are: to find lowest costs possible and receive the highest quality services. The health care provider is delivering these services to patients. Their motivation is to: control the costs of supplying these services and increase their profit margins. The managed care organizations are trying control the costs that they are paying for health care services and increase their bottom line results. The regulators are concerned about if various health organizations following the law. Their main objectives are to: help control costs and make certain that the public is being treated fairly. The shareholders are interested in seeing their total returns rise. This means that they will place pressure on management to: control costs and increase their earnings as much as possible. (Duncan, 1997, pp. 24-30)

Explain how these participants can influence the role / functions / activities of managers in HSOs.

The patients can have an impact on HSO managers by: demanding that they begin receiving certain kinds of services. This will lead to shift in how managers are looking at: the way they are delivering various kinds of health care solutions to them. At which point, a change will take place in the organization's policies and procedures. This will have an impact on how managers are performing their jobs and the kind of activities they are allowed to engage in. (Feeny, 1986, pp. 47- 52) (Beam, 2005, pp. 69 -- 73)

The health care providers will have an influence on HSO managers based on the costs that they are charging for different services.

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This will force many executive to begin implementing strategies to control costs as much as possible. As this is impacting how they are performing their jobs and the kind of actions they are taking. Over the course of time, this will change how these individuals are performing their different duties and what areas they will focus on. (Feeny, 1986, pp. 47- 52) (Beam, 2005, pp. 69 -- 73)

The managed care organization will have effect on HSO mangers through: their attempts to control costs and limit access to expensive services (i.e. specialists). This will influence executives by causing them to embrace policies and procedures that could be similar. As, the HSO may have different customers and are offering contrasting services, yet the techniques that they are using to increase profits as well as control costs are what will influence these managers. Where, they are utilizing similar tactics to help their organization to achieve the same kinds of goals. This is influencing how they will view their roles and the actions they are taking in the organization. (Feeny, 1986, pp. 47- 52) (Beam, 2005, pp. 69 -- 73)

Regulators will influence managers by: forcing them to follow various provisions of the law and new changes that are being implemented. This will have an immediate impact on the ethical and legal responsibilities for these executives. At the same time, it will shape what kind of actions: the organization is taking and the type of relationship that managers will have with customers. (Feeny, 1986, pp. 47- 52) (Beam, 2005, pp. 69 -- 73)

Shareholders will have an impact on managers by placing pressure on the board of directors to increase the returns of the organization. They will encourage executives to enact in policies and practices that will help to improve the overall bottom line results. Over the course of time, this will influence the way these individuals are: performing their jobs and determining what areas are of most importance to them. (Feeny, 1986, pp. 47- 52) (Beam, 2005, pp. 69 -- 73)

These different elements are significant because, they are showing how there are a number of variables that will affect managers. Each one of them will work as a part of: the how the individual is viewing their responsibilities and what actions they are taking on a daily basis. As a result, the combination of them will affect the duties and the kinds of policies that are enacted at the organization. (Feeny, 1986, pp. 47- 52) (Beam, 2005, pp. 69 -- 73)

Explain how you can apply the concepts / materials / related to Managed Care to your interviews with your manager in an HSO.

These concepts could be applied to an interview by helping us to understand the kinds of challenges that HSO managers are dealings with. This is important, because knowing how these factors can influence them and the way their thinking will provide insights about their jobs. Where, they must serve as a go between for: the different interests and challenges that the organization is facing. As, they are expected to: maintain a fine balance between the various sides. The issue is ensuring that neither one of these participants gains to much influence over the manager.

As a result, understanding these concepts will help to create focused questions that will allow us to: understand the responsibilities, activities, functions and how they are changing in the future. This leads us to several questions that will be asked as a part of the interview. A few of the most notable include:

How do patients, health care providers, managed care organizations, regulators and shareholders influence the kinds of policies and practices of the company?

Which one of these different groups has the most influence on your organization? Why?

What are the biggest challenges that you are facing now and in the future?

Do you think that there is a particular group that will influence your organization in the future?

How have you been dealing with the various challenges your company has been facing?

In what ways, do these challenges and participants influence your positions and the kinds of activities you are engaged in?

These questions are important, because they will help us during the interview to understand what issues are influencing managers the most. This is the point that we can be able to know how these concepts and material can provide.....

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