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Managed care. Evolution and distinguishing features

J T Frakes1

  • 1Department of Medicine, University of Illinois College of Medicine at Rockford, USA.

Gastroenterology Clinics of North America
|January 24, 1998
PubMed
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.

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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.

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