Talk:Managed care

After
After further reading, this article is horrible. Very biased, I can hardly even glean any useful information from it. Roy Harmon 05:05, 8 May 2007 (UTC)

"But, as Paul Starr discusses in his landmark analysis of the American health care system (i.e., The Social Transformation of American Medicine), Ronald Reagan was the first mainstream political leader to take deliberate steps to reform American health care from its longstanding not-for-profit business principles into a for-profit model that would be driven by the insurance industry." Seems pretty biased to me. Unless there's some reliable source that quotes Reagan as saying "I took deliberate steps to..." or something like that I don't think you can really claim to know his motives and it's debatable if American health care's business principles have changed that much in the first place. I know doctors who practiced medicine before Reagan was president and they sure weren't planning on being poor. But I guess we have to accept everything the author of a "landmark" analysis has to say as fact. Anyway, I edited it to make it more neutral, but I really think it should be removed altogether. Roy Harmon 05:00, 8 May 2007 (UTC)

Overall, this page does not focus on the successes of managed care or the reason why healthcare costs are rising. Managed care was actually quite successful at reducing healthcare costs at several points in the past few decades, however it came at the expense of people being denied access to care and medicines they believed they needed. Healthcare costs are rising because the "tool kit" available to patients is much larger than it used to be. Health insurance corporations are simply a financing mechanism that spread risk among the insured, thereby allowing health plan members to access care that would otherwise be too expensive to most individuals. While its true that there are many opportunities to improve coverage and access Managed Care and HMOs should not shoulder all the blame. Nor should all their ideas be discounted simply because wholesale failures in the current system. To do so would be throwing out the proverbial baby with the bath water. Any answer will have complex implications. It will mean trade-offs between increased taxation, reduced choice, reduced access, and increased out of pocket costs. The so-called single-payer systems in Canada and parts of Europe are not the panacea many in the US believe them to be. In fact, in Canada and other "single-payer" systems the government provides a full-coverage safety net, however individuals of means purchase supplemental insurance, seek care at private institutions or abroad and pay out of pocket to improve their access and selection. The US needs a better safety net, but a full single payer system is unlikely to work.63.166.14.2 20:31, 26 March 2007 (UTC)

Actually, the removed section below is relatively accurate for "staff model" HMO's. There are a variety of models, incuding so-called "staff models" where the HMO has employees; the Independent Practice Association ("IPA") and even "mixed" models. In fact, many of the seemingly "staff" models like Kaiser are really a conglomeration of contracted legal entities. For example, in CA where physicians must either contract as an independent contractor or be employed only by another physician or a governmental entity, Kaiser physicians are employed by a Kaiser physician's group which contracts with Kaiser. Kaiser hospitals are separate from the physician's group. In IPA type models, sometimes individual physicians contract with the IPA, or sometimes the physicians form a group, and the group contracts. What is at issue is how much financial risk each entity bears for the cost of providing care. The article is inaccurate in that even staff models may have satellite clinics throughout a region.

I removed the following section. I am confident that HMOs do not necessarily employ the health care providers: Look at Health Maintenance Organization, under "Types of HMOs" for various models; also, it doesn't match my experience. I don't know enough to rewrite it, but I know it's incorrect. "Physicians, nurses and other healthcare providers on the staff of HMOs work as salaried employees. They are generally housed at a central office location, rather than seeded throughout the community. They render care according to guidelines established by the corporate managers of the HMO, and may receive additional instructions in specific cases.  The nature of these guidelines and instructions are invariably to provide the least costly and uncomplicated form of care for patient diagnosis, which is usually made on the basis of the least costly diagnostic procedures, moving to more costly procedures only as a last resort."

Caveat: I'm new to this and this is my very first edit ever, so please assist me by further editing and/or feedback if you can.... I changed this: "under which they agree to capitate their fees at a level approved by the insuror". to "under which they agree to accept the reimbursement that was negotiated at rates agreed upon between themselves and the insuror at the time of execution of the contract". I may revise this to be more concise - and some other things, but capitation is not used in the correct context here. Capitation, in the healthcare setting, refers to a system of a flat reimbursement to the provider for each member in the capitated group, regardless of whether any particular member seeks services for the duration of the capitated arrangement, usually monthly. It's a somewhat confusing concept to folks who are not familiar with it in a healthcare environment. Also the edit above is correct, many HMO providers these days are NOT employed by the HMO (Kaiser, quoted as an example of an HMO in the article, generally, is an exception to this). Houmantx 06:18, 13 December 2005 (UTC)

This article needs work....
Much of the information, particularly under the "HMO" section, is incorrect these days. HMO's are far less strict than previously, and many now have an "open access" option whereby a selection of a gate-keeper, or PCP, is no longer required. In fact, they are indistinguishable from PPO plans. I will work on this when I have time, or somebody else please do it. I just hate to see incorrect information here! If a grade-school student had to write a paper on managed healthcare and relied upon this information, they would flunk!! 00:01, 30 April 2006 (UTC)

NPOV
Besides the criticisms levied above (namely, that the article reflects an out-of-date perception of the healthcare system), this article has NPOV problems. In particular, the article attempts to place all of the blame on problems with the system on health insurance companies, accusing them of malice and anticonsumer behavior while ignoring any benefits to managed care (in particular, lower prices). Oftentimes, such as in the article's discussion of medical inflation, when the reality doesn't match the authors' viewpoint, the article just makes up analysis.

Overall, this page needs a serious rewrite. Cheers, Vectro 16:34, 18 January 2007 (UTC)

---you're right Vectro, we should also include a nice NPOV objective listing of the rapidly increasing salaries of insurance executives. - (unsigned comment)

I imagine that if you cross reference insurance company executive salaries with executive salaries at comparable companies, you'd find no difference. The "insurance companies are big meanies" attitude isn't going to help this article.68.61.241.9 07:18, 26 April 2007 (UTC)

I'm having trouble discerning how this article is biased in its information. It seems rather accurate. T.C. Craig 19:22, 21 May 2007 (UTC)

While much of the information may seem irritating to some, the factual accuracy cannot be disputed. 1.) The medical insurance industry is a successful for-profit model. 2.) The current model was developed by Nixon and elaborated by Reagan with industry guidance. 3.) The "gatekeeper" model is still very real - I've dealt with it personally. Perhaps a rewrite showing that some HMO's have one, and some don't. 4.) It WAS touted as a way to lower inflation. Has it lowered inflation?

I think this article is rather accurate, though poorly written. T.C. Craig 18:29, 28 May 2007 (UTC)

What is it?
What is managed care? The article doesn't explain what it is, just what it's done — or more to the point, what different people think it's done. Nyttend 01:50, 7 June 2007 (UTC)

Exactly, we need a definition since the term "managed care" is simply a label that can't be interpreted literaly. The article gives examples of some things such as PPOs and HMOs, but where is the line drawn between "managed care" and "unmanaged care". Examples of insurance plans or healthcare systems that are not "managed care" would be useful, but a clear definition is essential.

I noticed what may be a major factual discrepancy in the article. Quote from the article: "But managed care has not been successful in lowering the rate of medical inflation. In fact, U.S. medical inflation is now two or three times the rate of overall inflation, as it was during much of the 1980s" My research (data taken from http://www.cbpp.org/11-13-06health.htm) showed me that health care expenditure per benificiary has been increasing at a slower rate than the private sector since 2000, and the grand total medicaid costs decreased in 2006. Even though the article does not claim to have narrowed down to cause of the decrease in health cost to managed care, it's clear that the (currently negative) medical inflation is not two or three times the national inflation rate. --John F. III 04:15, 28 July 2007 (UTC)

Re-instate Gatekeeper physisican as an international article?
I was looking for an article on Gatekeeper functions in health care systems and discovered that an original article Gatekeeper physician had at one time been created which seems like a good idea. But it now redirects to the article Managed care which is a purely U.S. term and to me seems inappropariate in a global context.

Many international health care systems use doctors as gatekeepers to ensure equitable access to health care resources and in the countries where I have seen it working, it is largely successful at containing costs and maximizing efficiency. The US experience seems to be rather the exception and not the rule. I was therefore wondering if I should re-instate Gatekeeper physician as an independent article so that it could be more internationally based. It could point to Managed care in the case of an example in US insured medicine.

I was at the same time wonndering whether there are Gatekeeper functions held by doctors in the US outside of HMOs and the like. For example in the military or veterans health care systems, or in the programs for native indian americans which are government controlled. It would seem highly likely but I do not know anything about these systems other than the limited sources that I have read which does not enable me to decide one way or another.

Comments please. --Tom (talk) 17:31, 20 May 2008 (UTC)

need some help with the Case management (USA health system)
this article on case management needs some expert attention please. I have recently started a Case management (disambiguation) page as the there are other case management terms, including a more general term medical case management Thanks for help Earlypsychosis (talk) 08:22, 2 July 2009 (UTC)

Intro
The introductory paragraph is one, single very long sentence. And it's incomprehensible. Could someone who understands the topic please improve on this? 78.16.228.250 (talk) 19:18, 30 May 2011 (UTC)

Dr. Ma's comment on this article
Dr. Ma has reviewed this Wikipedia page, and provided us with the following comments to improve its quality:

"I would think that a general definition should indicate non financial management of health care by insurers and integrated insurer-provider organizations. They may or may not reduce cost, but patients cannot freely choose services. The many techniques are listed fairly comprehensively. It is fair to say that some elements of managed care is present in almost any private health insurance plan. For Medicare, there is an explicit Medicare Advantage HMO plan, but otherwise Medicare enrollees are not subject to managed care. The US Health Care reform has not changed managed care much. The Centers for Medicare and Medicaid Services do encourage another form of managed care by the name of Accountable Care Organizations: a group of providers will invent their own managed care protocols due to capitation payments (fixed payment per enrollee per time period---regardless of health care uses and costs)."

We hope Wikipedians on this talk page can take advantage of these comments and improve the quality of the article accordingly.

Dr. Ma has published scholarly research which seems to be relevant to this Wikipedia article:


 * Reference : Philippe Chone & Ching-to Albert Ma, 2005. "Asymmetric Information from Physician Agency:Optimal Payment and Healthcare Quantity," Boston University - Department of Economics - Working Papers Series WP2005-006, Boston University - Department of Economics.

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