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Managed care. Evolution and distinguishing features
1Department of Medicine, University of Illinois College of Medicine at Rockford, USA.
Gastroenterology Clinics of North America
|January 24, 1998
Summary
Managed care systems evolved from 19th-century prepaid services to today's integrated networks. Understanding its history and features is crucial for providers navigating cost containment and quality demands.
Area of Science:
- Health Services Research
- Healthcare Management
- Public Health Policy
Background:
- Managed care emerged in the US due to employer and government demands for cost containment, improved access, and quality.
- Its origins trace back to 19th-century prepaid health services for immigrant workers, evolving through prepaid group practices.
- The growth of Health Maintenance Organizations (HMOs) in the 1970s, spurred by health reform legislation, significantly shaped modern managed care.
Observation:
- Current managed care models involve contracted providers offering services at reduced rates.
- Patient care pathways are directed towards these contracted providers.
- Managed care organizations (MCOs) influence clinical decisions via utilization management and quality assurance protocols.
Findings:
- Financial risk is increasingly transferred from payers to providers, influencing clinical decision-making.
- Managed care structures incentivize provider integration and greater reliance on management information systems.
- Key characteristics include limited provider networks, negotiated reimbursement rates, and provider-driven financial risk.
Implications:
- Successfully caring for patients requires understanding managed care's historical context and distinguishing features.
- Effective management of the risk structure is essential for providers in this evolving healthcare landscape.
- Professional success in the current healthcare delivery environment necessitates adapting to managed care's unique pressures.