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Managed health care.

¹Certified Employee Benefits Specialist, Double Oak, TX 75067.

American Journal of Hospital Pharmacy

|April 1, 1989

Summary

This summary is machine-generated.

Managed care principles, including prospective pricing and risk-sharing, control healthcare costs by influencing provider behavior. These strategies impact pharmacy services and overall healthcare delivery.

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Area of Science:

Health Services Research
Healthcare Management
Pharmacy Administration

Background:

Managed care is a healthcare system designed to control costs and improve quality.
Key components include prospective pricing, utilization review, and provider risk-sharing.
The industry comprises health maintenance organizations (HMOs), preferred provider organizations (PPOs), and managed fee-for-service plans.

Purpose of the Study:

To describe fundamental components of managed care.
To discuss the development of managed care programs.
To review the impact of managed care on pharmacy services and healthcare outcomes.

Main Methods:

Review of managed care principles and industry structures.
Analysis of reimbursement strategies like capitation and negotiated fees.

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Examination of utilization management and review services.

Main Results:

Managed care shifts cost-control incentives to healthcare providers.
Utilization management is more effective for inpatient than ambulatory care.
Managed care has reduced inpatient hospital use and lowered prices for some services.

Conclusions:

Financial risk-sharing and utilization management are crucial for cost control.
Hospital pharmacies have adopted cost-management strategies like formularies.
Community pharmacies have adapted by forming administrative organizations to navigate managed care.