Challenges in Provider Relations for Managed Care



Introduction3

Discussion4

Principles4

Conflict of Interest4

Cost Savings5

Information Issues7

Provider Reimbursement7

The Real Problem8

Competence9

Communication Problems9

Quality of Care10

Continuity of Care10

Freedom of Patient11

Learning11

Conclusion12

References13

Challenges in Provider Relations for Managed Care

Introduction

Among the rich and industrialized countries of the world, US health care system is different because it carries out its purchasing, financing on the basis of private sector. The US citizens obtain their healthcare services by the insurance benefits that are offered to them by their employers. Employers get a prominent amount of tax subsidy on providing the insurance benefits to employees and their families. According to a survey, approximately 44 million people of the United States do not have any public or private health insurance coverage and they are not able to avail most of the medical services. Only a few are accessible to them (newsweek.com).

In an indemnity insurance system the patients are free to choose the healthcare providers for them and they pay visits to them. The providers then bill the insurer and those are compensated on the basis of fee-for-service program. These systems create the financial barriers like co-insurance and deductibles due to which a patient is not able to avail most of the services offered in an insurance plan. The indemnity insurance plans are slowly disappearing (Acob, JA. 2000). The managed care refers to the term that a range of methods of care that is provided to the patient along with its financing and delivery. The patients are required to select any program like per-capita and per-service and are provided the services according to it. There is several managed care plans offered to the patients (Blendon, RJ, et al).

Discussion

Principles

The managed care system has developed due to the needs of patients for controlling the cost of health. The principles that are followed by the managed care system include cost effective healthcare and high quality (Blendon, RJ, et al). A managed care system is the one which examines and provides a complete range of the healthcare services to the patients. It focuses on the prevention and health awareness programs and it encourages the best conditions of the care provided by an appropriate provider to the patient. It also promotes the use of incentives in providing the healthcare services like by the introduction of the cost sharing program.

There are many issues that are faced in the provider relations for managed care. The most common issues are discussed below.

Conflict of Interest

At the point of paying the financial incentives there are certain possibilities of the emerging of the issues of obligation. The methods of the payments that affect the pronouncement are capitation. Capitation is a process in which a fixed amount of money is paid to the provider weather they see the patient or never see him (Eiser, et al. 1999). Other methods of financial inducements include the compensation that is received by using the money provided by the managed care. Another way of inducement is holding back a specific percentage of the income and then this income is given ...