Managed CareDefining Managed CareBack in the Old Days…Paul Ellwood: The Father of Managed CareRise & Fall of Managed CareFFS vs. Managed CareForces of ChangeDo you know your ABC’s?Slide 9Managed Care TodayManaged Care ProsManaged Care ConsPhysician Controversy!Enrollees’ Discontent!Quality and RegulationConclusionHSCI 678 Intro to US Healthcare SystemManaged CareChapter 19Dr. Tracey Lynn KoehlmoosDefining Managed Care•Ill-defined, ill-applied and overused term.•Patient utilization and provider practices are managed by an entity with a fiduciary interest in the interaction between the two.Back in the Old Days…•Access to care increased 1960’s•Employers and Federal Govt--payors•Consumer’s choice of provider, unrestricted•Provider’s choice of services, FFS•Managed care (pre-paid healthcare) served a small segment of US populationPaul Ellwood:The Father of Managed CareRise & Fall of Managed Care•HMO Act of 1973, Paul Ellwood•1979 start of NCQA•1980’s, Employers focus on wellness •1996 HIPAA passed•By 1997, 8.1 million Americans in some form of managed care•2000 HIPAA enacted•2000 Death of Managed Care ?!?FFS vs. Managed Care•Individual patient•Acute Care•Overservice Incentive for providers•Unrestricted access to providers by the patient•Population•Disease Prevention/ Health Maintenance•Underservice Incentive for Providers•Barriers to providers/ Controls and restrictionsForces of Change•Sky-rocketing costs •Need to establish cost predictions•Societal need to account for expenditures•Optimal vs. maximalDo you know your ABC’s?Continuum of Managed CareManaged Indemnity Service Plans PPOs POS Open Panel HMO Closed Panel Increasing Cost and Quality ControlDo you know your ABC’s?•Evaluate MCO’s based on:–Set up, Provider Payment, Enrollee Incentive–Cost Savings Mechanisms, Risk Assumption•Alphabet Soup of Managed Care:–HMO (staff model), HMO (group model)–IPA/Network, PPO, EPO–POS, PSO, –IDS (PHO, IPA, MSO)Managed Care Today•92% of Employer Sponsored Insurance in Managed Care, 2002•60% of Medicaid•Medicare+Choice Plans on the decline•POS fastest growing model•Mergers, bigger MCO’s•11 HMOs capture 50% of enrolleesManaged Care Pros•1990’s—slow of healthcare expenditures•< admissions, shorter LOS, < tests •Reliable Outcomes Measurements•Best Practice Guidelines•Reduce waste and redundancy•Promotes prevention and promotion•Chronic Disease ManagementManaged Care Cons•Phys/Hospitals working to protect economic interests•Failure to arrest US health expenditures•Physician economic survival v. patient health•Potential “under service” due to short LOS•Lack of accountability for public health quality•Lack of developed and useful IS •Altered core function of insurerPhysician Controversy!•Gag Rules•Physician Autonomy•Physician SatisfactionEnrollees’ Discontent!•Consumer Choice•Selection Bias•Turnover•Consumer SatisfactionQuality and Regulation•Quality Research HMO = Indemnity•Should we leave MC to market forces?•Cost containment: Does MC work?Conclusion•Are the cost savings days over for good?•Is Managed Care Dead or just