The Purpose of Managed Care Health Insurance Plans is to Improve Healthcare Quality and Efficiency

Managed care health insurance plans aim to improve healthcare quality and efficiency by coordinating care and reducing unnecessary costs. This is achieved through a network of healthcare providers who work together to ensure patients receive the right care at the right time.

By reducing unnecessary hospitalizations and emergency room visits, managed care plans can lower healthcare costs for both patients and payers. According to a study, managed care plans have been shown to reduce hospital readmissions by up to 20%.

The key to successful managed care is effective communication among healthcare providers, patients, and payers. Regular care coordination meetings and patient education programs help ensure that everyone is on the same page and working towards the same goals.

By streamlining care and reducing unnecessary costs, managed care health insurance plans can provide better health outcomes and improved patient satisfaction.

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Managed care has a fascinating history that spans over a century. The first prepaid medical care was provided by a small number of physicians in the late 19th century to members of fraternal orders, unions, and other worker associations.

These early prepaid plans were relatively small and grew slowly over time. By the early 20th century, railroad, mining, and lumber companies began organizing their own medical services or contracting with medical groups to provide care for their workers.

Prepaid contracts between employers and employee associations became more common during the Great Depression of the 1930s. However, it wasn't until the 1970s that the federal government and large private companies started encouraging their workers to join prepaid forms of health care groups.

The Health Maintenance Organization Act of 1973 marked a significant turning point in the development of managed care. This act encouraged the rapid growth of Health Maintenance Organizations (HMOs), the first form of managed care.

By the mid-1980s, employers were increasingly turning to managed care to contain the rising cost of providing health care benefits to workers. This shift led to a significant increase in managed care enrollments, particularly in the 1990s. Today, the vast majority of privately insured Americans are covered by some form of managed care.

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Managed care health insurance plans come in different forms, each with its own set of rules and benefits.

There are several types of managed care plans, including Health Maintenance Organizations (HMOs), Preferred Provider Organizations (PPOs), and Exclusive Provider Organizations (EPOs).

HMOs are a type of managed care plan that often have lower monthly premiums but manage care by placing restrictions around which providers enrollees can see.

In an HMO, enrollees are required to see in-network providers and typically need to see their primary care provider (PCP) and obtain a referral before seeing a specialist.

PPOs, on the other hand, offer more flexibility to enrollees and generally have larger provider networks, but may cost more.

Enrollees in a PPO can seek care from both in-network and out-of-network providers, and referrals from a PCP are not usually required to access specialty care.

EPOs typically offer a local network of providers and hospitals for enrollees to choose from and usually cost less than a PPO plan.

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Managed care plans come in various forms, each with its own set of rules and benefits. There are several types of managed care programs, ranging from more restrictive to less restrictive.

HMOs, or Health Maintenance Organizations, offer lower monthly premiums in exchange for restrictions on which providers you can see. They typically require you to see in-network providers and obtain a referral from your primary care provider to see a specialist.

HMOs have been around since the 1960s, with the first HMO concept proposed by Dr. Paul Elwood. They are licensed at the state level and are required to have a federally-qualified HMO status.

In an HMO, each member is assigned a "gatekeeper", a primary care physician responsible for their overall care. Specialty services require a specific referral from the PCP to the specialist.

One of the benefits of HMOs is that preventive care appointments, such as annual wellness visits, are fully covered.

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Exclusive Provider Organizations, or EPOs, are similar to HMOs but offer a local network of providers and hospitals for enrollees to choose from. Out-of-network care is generally not covered except in cases of emergencies.

EPOs are often less expensive than PPO plans but have restrictions around seeking in-network care, which is an important consideration for enrollees.

Preferred Provider Organizations, or PPOs, offer more flexibility to enrollees and generally have larger provider networks. They allow enrollees to seek care from both in-network and out-of-network providers.

PPOs use a preferred provider network and offer in-network care at a lower price. Referrals from a primary care provider are not usually required to access specialty care.

Point of Service, or POS, plans are a hybrid of the HMO and PPO care models. They offer enrollees flexibility to see providers that are in-network or out-of-network but pay a higher share of costs.

POS plans may require you to see your primary care provider for a referral before seeking specialist care.

Indemnity insurance plans have evolved to incorporate some managed care features, such as precertification for non-emergency hospital admissions and utilization reviews. These plans are sometimes described as "managed indemnity" plans.

Managed indemnity plans are a type of traditional or indemnity health insurance plan that has added some managed care features. This is a departure from the traditional indemnity plans that simply reimbursed medical expenses without any oversight.

Some key features of managed indemnity plans include precertification for non-emergency hospital admissions and utilization reviews. This helps ensure that medical care is delivered efficiently and effectively.

These plans are designed to provide financial protection while also promoting healthcare quality. By incorporating managed care features, managed indemnity plans aim to reduce healthcare costs and improve patient outcomes.

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Cost sharing is a key aspect of managed care plans, and it's designed to help keep costs down. High-deductible health plans are a common example, where consumers are incentivized to select cheaper providers and use less healthcare.

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These plans can be effective in reducing costs, but they can also be a challenge for those who need more medical care. In fact, high-deductible plans are used by insurers to keep costs down by encouraging consumers to be more mindful of their healthcare expenses.

Reference price schemes are another cost-sharing method, where a health insurer will only pay a certain amount for a service, and anything above that must be paid out of pocket. This approach can be beneficial for consumers who are willing to shop around for lower-cost options.

Managed care health insurance plans typically use a panel or network of healthcare providers to deliver care to enrollees. This integrated delivery system often includes a provider network, formal utilization review and quality improvement programs, and an emphasis on preventive care.

One of the key features of managed care is the use of a provider network, which enrollees are required or incentivized to use. This network typically includes designated doctors and healthcare facilities.

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Formal utilization review and quality improvement programs are also a key component of managed care. These programs include disease management and case management, which help to improve patient outcomes and reduce costs.

Here are some common techniques used in managed care:

Utilization review is a key technique used by payers to manage the cost of health care benefits. It involves assessing the appropriateness of healthcare services before they are provided.

Utilization management criteria are medical guidelines developed using evidence-based criteria or guidelines. These criteria can be created in-house, acquired from a vendor, or adapted to suit local conditions.

Two commonly used utilization management criteria frameworks are the McKesson InterQual criteria and MCG, previously known as the Milliman Care Guidelines.

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Managed care techniques are designed to provide enrollees with coordinated and efficient healthcare services. The most characteristic form of managed care is the use of a panel or network of healthcare providers, known as a provider network.

This network typically includes designated doctors and healthcare facilities, which enrollees are required or incentivized to use. Formal utilization review and quality improvement programs are also common, including disease management and case management.

An emphasis on preventive care is another key feature of managed care, including wellness incentives and patient education. This approach aims to prevent illnesses and promote healthy behaviors among enrollees.

Some managed care plans use formal utilization review and quality improvement programs to ensure high-quality care. These programs help identify areas for improvement and implement changes to enhance patient outcomes.

Managed care techniques can be applied to both network-based benefit programs and benefit programs that are not based on a provider network. This is sometimes described as "managed indemnity."

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Health maintenance organizations, or HMOs, offer a unique approach to healthcare. They're often less expensive than other options, with lower monthly premiums.

HMOs manage care by restricting which providers you can see. This typically means seeing in-network providers, those directly contracted with the plan.

You'll usually need to see your primary care provider (PCP) and get a referral before seeing a specialist. Preventive care appointments, like annual wellness visits, are often fully covered.

HMOs are licensed at the state level, under a license called a certificate of authority (COA). They're not licensed like insurance companies, but rather under a specific regulatory structure.

In an HMO, each member is assigned a "gatekeeper", a PCP responsible for their overall care. Specialty services require a referral from the PCP to the specialist.

Non-emergency hospital admissions often require pre-authorization by the PCP. Services performed by a provider not an employee of or approved by the HMO may not be covered, unless it's an emergency.

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In the US, the health insurance industry is dominated by a few large players. As of 2017, the top 10 health insurance companies account for about 53% of revenue, while the top 100 account for 95%.

The industry has also seen a significant shift towards provider-sponsored health plans, which can form integrated delivery systems. Kaiser Permanente is the largest of these, as of 2015.

Kaiser Permanente stands out in terms of consumer satisfaction, ranking highest in 2018.

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The US health insurance industry is dominated by a few large players. As of 2017, the top 10 health insurance companies account for about 53% of revenue, and the top 100 account for 95%.

Aetna, Anthem, Cigna, Health Care Service Corp, UnitedHealthcare, and Centene Corporation are the largest commercial plans in the US. These companies offer a range of health insurance plans to millions of Americans.

Smaller regional or startup plans, such as Oscar Health, Moda Health, and Premera, are also available. However, they account for a much smaller share of the market.

Kaiser Permanente is a notable example of a provider-sponsored health plan. It was the highest-ranked commercial plan by consumer satisfaction in 2018.

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In some US states, healthcare providers are incentivized to improve quality through financial rewards.

New York, for example, ties Medicaid payments to quality metrics, offering bonuses for meeting certain standards.

These incentives aim to drive better patient outcomes and more efficient care.

States like California and Massachusetts also offer similar programs, encouraging healthcare providers to prioritize quality over volume.

By linking payment to quality, these states hope to create a more patient-centered and cost-effective healthcare system.

In California, Medicaid payments are adjusted based on a provider's performance on quality measures, such as readmission rates and patient satisfaction scores.

This approach has led to improved health outcomes and reduced costs in some areas, but its effectiveness varies by state.

Managed care is a type of health insurance plan that coordinates physical health, mental health, and substance use disorder treatment services under one plan. This approach provides whole-person care, covering preventive, primary, specialty, and other health services.

Most managed care clients, like those with Apple Health, have their care coordinated by a managed care plan that pays a monthly premium for their coverage. This means seeing providers within their plan's network is usually required, unless prior authorized or for urgent care.

Newly eligible and renewing clients can choose or be auto-assigned into a managed care plan, which is often backdated to the beginning of the current month. Changes to managed care plans can be made at any time, typically taking effect the month following the change, unless requested in the last seven business days of the current month.

Apple Health Core Connections is a statewide managed care plan for Washington State foster care enrollees, administered by Coordinated Care of Washington. You can reach Apple Health Core Connections at 1-844-354-9876.