mc connell pp_ch26

© 2010 Jones and Bartlett Publishers, LLC

Umiker's Management Skills for the New Health

Care Supervisor, Fifth Edition

Charles McConnell


Chapter 26

Managed CareManaged Care


Managed Care

The principal form of managed care

organization is the health

maintenance organization (HMO).

HMOs were created as a result of

the HMO Act of 1973.


Managed Care Focus

Since its inception managed care has

been focused significantly on cost

control. The continuing question has

been, “Can costs be reduced without

adversely affecting the quality and

availability of services?”


Managed Care Features

Complex organizational arrangements

between institutions and clinicians

Explicit financial incentives for

providers and enrollees

Defined access to the physician panels

and other services


Managed Care Features

Strong controls on the use of services,

especially health care specialists

Coordination and integration of services

Accountability for an enrolled

population and for quality of care


Capitation Reimbursement

One special feature of managed care is

capitation reimbursement, a prospectively

determined payment system.

This approach transfers financial risk from

the insurer to the provider based on some

anticipated level of activity


The “Gatekeeper”

A significant feature of all managed

care plans is the use of the primary

care physician as “gatekeeper” to

the health care system.


Other Managed Care Plans

In addition HMS, there are:

independent practice associations (IPAs),

preferred provider organizations (PPOs),

point-of-service (POS) plans,

physician–hospital organizations, and

physician management companies.


Managed Care Challenge

The principal challenge of managed

care is to ensure that every plan

delivers high-quality service at an

affordable price to all enrollees.


Additional Challenging Factors

Today’s patients show less trust and

less respect for care providers than

patients of an earlier generation.

Care providers are more stressed;

under-staffing is common.

Work units are forced to adjust to

frequent organizational changes.


Additional Challenging Factors

Reengineering,” and other such reorganizing

activities have reduced job security.

Increased errors are seen by some as a

problem.

Reductions of space and budgets may

restrict services.

Rapidly growing regulatory bureaucracies.


Provider Strategies

For health care institutions,

especially hospitals, successfully

surviving the transition to managed

care requires a blend of well-timed

and coordinated strategies.


Clinical Pathways

Written templates of expected

interventions and outcomes for

selected groups of patients. These

allow health systems to standardize

care and to improve the processes

and outcomes of care where possible.


Patient Focus Care Model

A health care delivery structure that

streamlines care by restructuring

hospitals into delivery units that are

more self-sufficient. This type of

system provides care to each

patient by using fewer providers.


Benchmarking

Clinical benchmarking in which physician

practice patterns are matched.

Operational benchmarking, which

compares organizations from the

standpoint of staff productivity, staffing

mix, and the use of space and resources.


Needed Education

Manager and supervisors need

educational programs on the subject of

managed care. Management should

provide supervisors with training in

developing budgets that reflect clinical

realities, cost accounting, and strategic

planning.


Survival Competencies

Clinical management: resource

allocation, productivity measurement,

disease management

Financial management: budgeting,

management of variance, cost

analysis, statistics


Survival Competencies

Information management:

communication flow, medical

records, quality improvement

Leadership: personnel

management, communication skill,

team building, time management.


Employment Flexibility

Many employers are looking for

multidisciplinary professionals,

managers, and supervisors to

replace highly specialized personnel

in certain settings


Managed Care Positions

Case Managers Utilization Reviewers Advice Nurses Authorizing Authorities Marketing and Sales Agents Claims and Benefits Administration

Personnel Actuarial Service Personnel

mc connell pp_ch26

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