A significant number of people living in the US have health insurance cover, and a majority of them are under the managed care program. Throughout history, Americans have been concerned about the cost of healthcare. As a result, the US government implemented a bill that defined managed care organization (MCO) as an organization that works with insurers and self-insured employers and funds and delivers health care through a system of the provider network that determines the specific services and products offered to clients. Although there are disadvantages, MCOs aim to provide managed health care services to enrolled clients while maintaining a low cost of health care through preventive medicine and patient education.
Admittedly, the MCOs control the cost of health care through provider networks and utilization management. They ensure that healthcare facilities meet specific standards and requirements by implementing practices such as peer reviews, legal mandates, contract language and obligations, and disease- and treatment-specific procedures (Seehusen, Britton, & Duys, 2020). For providers to become a member of the MCO network, they have to meet these standards and agree to the pricing arrangements that reduce the overall costs of medical services. Another means that MCOs use to control the healthcare costs is the utilization management. Here, the MCOs examine the relevance and appropriateness of a given care model on a case-by-case basis (Seehusen, Britton, & Duys, 2020). The most common strategy is the preventive care that fosters routine physician checkups and age-based screening for different conditions. This approach works on the premise that cost before treatment is usually low.
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Moreover, the proponents of MCOs believe that they offer benefits to the patients. One of the advantages is that they provide leadership in the redesigning of care to eliminate patient harm under different conditions, physicians, and healthcare facilities (Seehusen, Britton, & Duys, 2020). Using the cost-controlling ability, MCOs ensure that patients receive high-quality health care services. They educate patients about the recommended healthcare facilities and treatment procedures. More importantly, MCOs direct hospitals and physician groups to assume a certain degree of financial risk that includes sharing savings and losses after and before treatment procedures (Enthoven, Fuchs, & Shortell, 2019). As a result, patients do not have to bear the high costs of healthcare despite their conditions. Members under the MCOs acquire generic drugs at low prices.
Nevertheless, MCOs’ cost-controlling measures have disadvantages. Among them is the fact that they limit patients to given physicians and hospitals, and when one seeks care outside the group, they have to pay an additional fee (Enthoven, Fuchs, & Shortell, 2019). This price controlling policy denies patients the freedom of autonomy. Besides, it limits patients’ access to care. The majority of the physicians whose patients are under the MCOs claim that there are barriers that prevent them from delivering high-quality care (Highfill, 2017). This outcome is based on the idea that MCOs determine what amounts to quality and safe care practices. At times, patients pay highly for healthcare without the guarantee of receiving high-quality care.
Overall, MCOs serve as cost controlling agencies in healthcare. They ensure that there is the proper utilization of healthcare resources by attaching patients to given physicians and hospitals. One of the cost-controlling approaches is the emphasis on delivery of preventive medicine that lowers the costs that patients would have incurred in the treatment of a given condition. In turn, patients benefit from MCOs since they ensure that physicians adhere to safety and quality standards. Besides, patients can purchase generic drugs at low costs. However, MCOs have disadvantages that include patients paying additional costs when they seek services outside their range. The rules set forth by MCOs can also limit the physicians from incorporating additional but yet vital medical procedures. Regardless, MCOs have managed to lower the cost of health care for the majority of Americans.
References
Enthoven, A., Fuchs, V. R., & Shortell, S. M. (2019). To control costs, expand managed care, and managed competition. Journal of the American Medical Association , 322 (21), 2075-2076.doi:10.1001/jama.2019.17147
Seehusen, C., Britton, R., & Duys, D. (2020). Managed Care Organizations in counseling practice, research, and education. The Journal of Counselor Preparation and Supervision , 13 (1), 9.doi:10.7729/131.1341
Highfill, T. C. (2017). Patient outcomes and managed care: What was the impact of the state regulatory backlash? Virginia Commonwealth University . Retrieved from https://scholarscompass.vcu.edu/cgi/viewcontent.cgi?article=5856&context=etd
