HR essay on: Care system in health care organization

Introduction

            This activity is mainly aimed at performing a research of a local managed care system so that they can be effectively evaluated on the main functions performed by them. A brief research of the local managed care system would allow identifying the different types of managed care including their strengths and weaknesses. As such, the identification of strengths and weaknesses of the managers’ care would lead to the preparation of a letter targeted at the editor of local newspaper that would specify about the strengths and weaknesses that would be identified. The research to the local managed care resulted into the identification of two most prominent examples of managed care and those are:Health Maintenance Organizations (HMOs)

• Preferred Provider Organizations (PPOs).

These are the two most common types of managed care plans that aim at providing health care services to the enrolled members at lower costs. The evaluation of the local managed care as performed has resulted into the identification of a wide range of functions in controlling costs (Moseley, 1999). Some of these are indicated below:

• Utilizing provider networks in providing care services to patients at reduced costs.
• Procedures are approved in advance to deliver the health care services.
• Utilization management of treatment guidelines and utilization review.
• Peer review and second opinion.
• Complete audit of the procedures to reduce chances of errors in service delivery.

Letter

To: The Editor of Local Newspaper

Subject: Strengths and Weaknesses of HMOs and PPOs

The two examples of managed care are HMOs and PPOs, whose advantages and disadvantages are as discussed. The main advantage of HMO is that the health premium charged to both the employee and the employer is comparatively lower, and thus the lower cost offered by this plan is the major aspect behind the selection of this health care service plan by the members. Also, the HMO plans offers a wide selection of physician and hospitals and this allows the customers to avail the variety of health care services, and such wide availability of selection at lower costs is highly advantageous to them. In addition to this, HMO care is provided by doctors with the guidelines of HMO. This also benefits the patients to a large extent. However, the main weakness of HMO is that the enrollees can refer to only those doctors and physicians who are under the listed category of such plans or the hospitals with which HMO have pre established contract. This implies that in case if a particular physician is not listed, it would not become possible for the members to avail the services of such a physician. Another major disadvantage of HMO plans is that once the regular physician gets delisted from the HMOs list of physicians, it would create difficulty for the patients who are regularly under the treatment process with that particular physician, as they are then required to search a new physician (Ralph and Taylor, 2005).In addition to HMOs, PPOs also have certain positive points as well as certain weak points. The major strength point of PPOs is that they offer a wide range of opportunities in selecting physicians to choose from as per their health needs. PPO plans also include the specialist treatment facility which is not included in case of HMO plans. There is higher level of flexibility provided to members in selecting a physician, doctors/specialists and another major advantage to the members is that they can also select the physicians/doctors who are not listed in the physician lists with which PPOs has contracts for delivery of services. This is the most important feature of PPO and it is the major factor leading to people enrolling to services as offered by them, as they get access to services of specialized physician or the doctors to whom they want to consult. Members in case of PPO plans can go to non-network doctors for consultation. Apart from having these strength points, there are certain weaknesses as well. To enroll to PPOs, the members are required to pay a premium rate which means that the cost of availing healthcare services in case of PPO plan is usually higher. Since PPOs offers flexibility, the members are charged with a premium rates in availing their healthcare services (Kongstvedt, 2012).

Reflection of Experience

Introduction

            Managed care organizations are important healthcare service providers that aim at achieving cost effectiveness in providing health care treatments to patients. These organizations provide health care services to their enrolled members through various plans. The two major plans as available to MCOs are Health Management Organizations (HMO) and Preferred Provider Organization (PPO). These plans are important means of providing health care services to patients at relatively lower costs. However, in ensuring the effective delivery of services, there are various factors that are required to be considered by MCOs under their various plans (Kongstved, 2009).

            This part of the paper is aimed at analyzing managed care system with particular emphasis placed on the important plans as included within their service offerings. In addition to this, the advantages and disadvantages of the managed care systems will be analyzed in detail in this part of the paper which will be followed by an assessment of the new thoughts and insights for future applications. Thus, the main objectives of this paper are to analyze the managed care systems and their relative advantages and disadvantages and as this is a reflection paper so the analysis would mainly be a reflection. Lastly, on the basis of findings from the analysis, it will be concluded briefly in the conclusion section of this paper.

Analysis of Managed Care System

            From the analysis as undertaken about the managed care organizations, it has been found out that managed care organizations are aimed at providing healthcare services to their patients. They basically acts as a third party whereby they have contracts with providers to provide healthcare services to the members enrolled with such organizations. The core feature of such kinds of health care service provider organization is that they aim at achieving higher quality of care to the members enrolled with them and that too at lower cost. From the analysis of the managed care systems as performed, it is experienced that these organizations are able to provide healthcare services at lower costs mainly because they are being contacted by the providers and encouraged to attract more and more patients. As a result these services are availed by the consumers in huge numbers; and these MCOs are able to provide the healthcare services at relatively cheaper cost.            Although managed care systems provide services of healthcare, yet it is not feasible to ensure proper delivery of healthcare services to all the categories of customers and the analysis of the managed care systems have indicated that they have classified their services into various important categories. This is mainly done to ensure the effective delivery of healthcare services to patients and the categorization helps in classifying the services as per the requirements of different customers. On the basis of performance of analysis of managed care system, it has been experienced that there are two major plans as provided by managed care organizations in order to cater to the diverse needs of its customers regarding the healthcare services. These are mainly Health Maintenance Organizations (HMO) and Preferred Provider Organization (PPO). This classification has allowed the delivery of healthcare services as per the different customer needs. An analysis of the important concept of HMOs and PPOs is performed as follows:

Concept of HMO and PPO 

The HMOs are identified as prepaid health plans whereby members are required to make a monthly payment for which they are provided with care facilities by HMO which includes hospital stays, doctor’s visits, surgery, emergency care etc. It is a kind of managed care organization that provides health insurance coverage to members through the major providers with which HMO has contract for delivery of services. HMOs are offered with opportunities by the providers to attract more and more patients so that they can be offered with heath care facilities at lower cost. Contrary to this, PPOs are also an important type of managed care organizations that provide covered services at discounted costs to the subscribers. The only additional feature with the members enrolled at PPO is that they have the opportunity to select health care providers that are not a part of PPO network and for this facility; they are usually charged a higher cost for the services (Green and Rowell, 2010).

Advantages and Disadvantages of Managed Care Systems:

            From my experience of the analysis of managed care system, I have identified that such kind of organizations offers a wide range of advantages as well as disadvantages. The core philosophy behind providing healthcare services through managed care is to achieve cost effectiveness and higher quality in the process of delivering care. Since, many people cannot afford the healthcare services mainly because of higher costs associated with them; the managed care system is an alternative to them in availing better quality of healthcare services at cheaper costs. This can be considered as the major advantage with the managed care systems. Apart from this, another major advantage as available to members of managed care system is the wide availability of the network of such system which allows easy accessibility to any major health related services to patients. The effectiveness of managed care system can majorly be identified in United States, as the concept of managed care system has gained tremendous prominence in such countries over the years (McKenzie, Pinger and Kotecki, 2011).            Apart from having these advantages of the managed care system, the performance of the analysis of its functional operations indicates that there are certain loopholes that are also involved in the process of delivering health care services through these managed care systems. One of the major problems or the disadvantage of the managed healthcare system as identified from the analysis is that these systems have certain rigid rules that act as a barrier to members in availing the most efficient services with respect to attaining better health conditions. The major loopholes as identified is in respect to HMOs whereby the members have access to only those hospitals, physicians and doctors with which HMOs has a contract. This implies that the members are not allowed to avail services from the specific doctor or physician with whom they want to avail services (McKenzie, Pinger and Kotecki, 2011).

            Although, members are allowed to get the treatment in case of PPOs from the service providers who is not in the providers list of PPO, but in availing such services, members are required to pay premium rates. In addition to this, in case of the HMO plan of managed care systems, it is difficult or a cumbersome process for the members in case if a particular physician or the doctor is delisted from the plan and during such situation, getting a new physician or doctor in availing the healthcare services is very difficult for the members. The core philosophy of the managed care system is to provide quality services at lower costs and in order to provide such services at lower costs, sometimes the concern of members can be ignored and thus this leads to poor quality of healthcare services as delivered to members. There are cases where the quality of managed care system has been questioned significantly and this is mainly because of the necessity on the part of such organizations to provide healthcare services at lower costs. These are the major weaknesses of the managed care systems as identified from the analysis as carried out throughout the entire paper about the managed care systems and the various plans offered by it (McKenzie, Pinger and Kotecki, 2011).

New Thoughts and Insights for Future Applications:

            From the analysis performed about the managed care system, there are certain new thoughts and insights that have emerged and these can be applied in future towards enhancing the overall delivery of care services in case of managed care organizations. As identified, the core philosophy of managed care organization is to achieve higher quality at lower costs; this can be effectively achieved from contracting with more number of healthcare service providers in delivering the care services. This would increase the flexibility on the part of enrollees in availing healthcare services in terms of making the selection of service providers in accessing services from such healthcare organizations. As such, the focus in the future should be on increasing the number of providers by contracting with, so that members can be offered by higher flexibility in selecting a particular physician or the doctor in availing the healthcare services. In addition to this, the quality of the healthcare services in such organization can be improved by following a process of prior approval of procedures of performing the delivery of health related services. This would lead to the attainment of higher level of effectiveness in the delivery of healthcare services by the managed care systems (Stahl, 2003).

Conclusion

            A brief analysis of the local managed care is performed along with its important features and the types of plans as offered by them. The performance of the analysis identifies that managed care systems are aimed at providing higher quality of healthcare services at lower costs and this is usually attained by them by way of classifying their services into HMOs and PPOs plans. These plans are aimed at catering to the needs and requirements of different customers with respect to their accessibility to different healthcare service providers.

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