Access and referral problems in managed care

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Accessto healthcare services is a significant determinant of the well-beingof members of a community. Effective management of illnesses such aschronic diseases is dependent on the availability of healthcareservices to the people who are in need. Access to care is affected bydisparities. Shi, Chen, Nie, Zhu, &amp Hu (2014) state that thereare racial and socioeconomic disparities that determine the ease ofaccessing services. Uninsured adults in the USA are less likely toget preventive care and specialist services (Wang et al.,2013). Managed care is a system that exists to manage cost, utilizeand ensure the quality of health services. It is also affected bylimited access to care. This paper describes managed care system andidentifies access and referral issues. It also discusses techniquesfor improving access and referral process in managed careorganizations.

Accordingto Winston &amp Winegar (2014), managed health care is a system thatintegrates the payment and delivery of healthcare services andproducts to clients with the aim of providing the quality care at anaffordable cost. Hospitals, pharmacies, laboratories, and clinicsform the managed care provider system. Managed care organizationshave the responsibility of selecting hospitals, networks ofhospitals, or physicians to provide patients with a specified set ofservices. The selection of these healthcare entities is done based onthe criteria defined by the plan including quality concerns andcompetitively priced services. Managed care is an insurance plandesigned to reduce the cost of healthcare to members (Richard E. &ampJoav M. (2013). The major plans in this system include preferredprovider organizations, health maintenance organizations, and pointof service. Members may pay more if they choose services offered bydoctors outside the plan.

Managedcare system improves access to healthcare services to its members.However, this objective can be undermined by the referral process.Authorization requirements allow managed care organization todetermine if a health problem can be addressed by a given specialist(Richard &amp Joav, 2013). If it does, the organization authorizes areferral to a specialist under contract to the MCO. When selectedphysicians cannot provide certain services, they may refer planmembers to other doctors outside the plan. Authorization is seldomopen ended and usually limited to the number of referrals except fordefined situations. It is usually expected that managed careorganizations should rarely involve themselves in the process ofauthorizing referrals.

Thereare times when clients are referred to physicians who are notenrolled in the managed care plan. Before doctors make referrals,they must seek approval from HMO (Winston &amp Winegar, 2014). Thisprocess of obtaining authorization faces several challenges. Thereare occasions when physician’s request to refer plan members aredenied inappropriately. Sometimes doctors don’t get any responsewhen they contact HMO approval line to get authorization for theirreferrals. As a result, enrollees find it difficult to access theservices they need to address health issues they have. They may lookfor help from doctors outside the plan, which is more expensive thanreceiving healthcare service from physicians within the plan.

Makingreferrals and authorizations require sound decision-making toguarantee enrollees quality services. The American Federation ofState, County and Municipal Employees (2017) reports that there areindividuals in charge referrals and authorization don’t have therequired competencies to make appropriate decisions. They makechoices based on fixed criteria which may not be flexible enough toaccommodate the needs of plan members. This phenomenon may lead toauthorization denials or approval of referrals for services that doesnot meet quality guidelines. The process of obtaining referrals isoften time-consuming. As a result, enrollees experience delays whileaccessing healthcare services. Managed care organizations andproviders sometimes disagree on what is medically necessary duringservice provision. This limits the range of services available toclients. Any time the process of referral is affected negatively,access to healthcare becomes limited.

Inmanaged care, patients and doctors have limited number of choices.Since employers switch plans and employees switch jobs, the chancesof having consistency in access to quality healthcare diminishes. Asa result, forming a long-term relationship between patients andphysicians becomes difficult. Enrollees only get access to healthcare services only when a gatekeeper physician permits or getapproval from the managed care organization. The chances forenrollees to access quality care are limited since managed careguidelines encourage doctors to conduct fewer tests, referrals, andhospital admissions. Plan guidelines don’t allow doctors to spendenough time with each patient.

Thereare strategies for improving access to care and referral process inmanaged care system. Frequent education and training of gatekeeperphysicians in essential in the improvement of the referral processand quality of healthcare services delivered to enrollees. Educationand training enrich these physicians with knowledge and skills thatenable them to make sound decisions about the necessity of variousmedical procedures and referrals (Winston &amp Winegar, 2014). Thisstrategy will help in reducing cases of approval denials. It makessure that enrollees are referred to qualified specialists due to theenhanced understanding of the gatekeepers.

Theapplication of information technology in managed care is asignificant improvement for enhancing referral process and increasingaccess to care without increasing cost. Communication technologyensures an effective communication between enrollees, physicians, andmanaged care organization (Brixey, Saba &amp McCormick, 2015). Itfastens the process of submitting requests for referral by doctorsand approval by the organization. The issues of delays and unansweredcalls when doctors try to get authorization for any referral willreduce. Electronic documentation of patient details enables thetransfer of demographic and insurance information and medical recordsfrom the primary physicians to specialists. The introduction of smartID cards for plan members will reduce delays caused by inquiriesabout patient details.

Processimprovement strategies can also be employed to make the referralprocess simple, quick, and seamless. This technique requires thesupport of the leadership of managed care organizations. The leadersand managers should review referral process data and identify theareas that need improvements. Denton, B. T. (2013) argues that thisprocess will enable this healthcare system to come up with bestpractices such as increasing the number of choices available topatients and doctors. Process improvement will change the guidelinesof managed care plans and make them flexible enough to enable accessto quality care by patients in different circumstances.


Theintroduction and evolution of managed care enabled both employers andemployees to cut healthcare costs. This system was successful inreducing cost but at the expense of access to health care services.It has limited the number of options available to enrollees andphysicians. The freedom of doctors to make referrals for servicesthey cannot provide is also affected. The process of making referralsis time-consuming and may encounter denials. Education and trainingenhance the understanding, decision-making skills and knowledge ofgatekeepers. Technology increases the availability of information toenrollees, physicians, specialists, and managed care organizations.Process improvement will help managed care organizations to attainchanges that make referral process quick and seamless. It can alsomake various managed care plans accommodative.


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