QualityAssurance and Access to Quality Care
Managedcare is a strategy used in the dispensation of healthcare services,especially when the resources are scarce. It works by contractingmedical services to other organizations who supply these amenitiesfor a select group of patients at a fixed price. Healthcare in the USis very costly. Initially, the aspect of insurance was set aside forthe wealthy. However, in the last few decades, people began to viewhealth insurance as a necessity due to the rise of various chronicillnesses such as diabetes, heart disease, and cancer. The concept ofgroup insurance minimized the individual cost of a medical personwhile also providing the necessary cover when needed (Steele &Merrick, 2013). The federal administration started to createoversights into these agencies that offered medical cover. Theventure was expensive, especially since the concept of healthinsurance had spread nationwide. The best way was to introducemanaged care into the system. The goal was to fragmentize the entirehealth provision sector while also trying to halt the steadily risingcost of healthcare (Steele & Merrick, 2013). The new systemensures proper utilization of resources since every expenditure mustbe accounted for unlike what was common in the past. This managementof healthcare ensures that the patients are covered in all aspects oftheir health from preventive measures to care for the terminally illpeople (Jung et al., 2015). However, there have been concerns byvarious people that question the quality of medical care that isoffered under the managed care system. They feel that the program isnot adequately monitored in terms of the actual service provided butonly looks into saving costs (Epstein et al., 2014). Other patients,even those with insurance, also face various challenges while tryingto access medical services or referral to other facilities.
Evenif the managed care system saves patients a lot of money, one of themajor drawbacks arises from the aspect of accessibility, quality ofcare and the process of referral. The entire objective of the programwas to share the cost between all of the stakeholders. Thus, thepatients, physicians, and other personnel are all encumbering equalresponsibilities for their involvement (Shi & Singh, 2015). Thequestion of accessibility to healthcare, especially when someone ison a network that has a large number of members is an issue. A personmay need medical attention for a common condition like heart diseaseor diabetes, but they are unable to get any help since all theexperts in that sector are swamped. The members in a particularsystem of the management care may be more than what the availableresources can support (Ferlie et al., 2013). The problem continues togrow in its severity since fewer people are going to medical school.As the years have gone by, there are fewer doctors, nurses and othermedical personnel that graduate. To make it worse, more peoplerequire health care since the advancements in the field of medicinehave led to the increase in the average life expectancy (Shi &Singh, 2015). More people are living with chronic disease, and thenumber keeps rising. Therefore, even if someone has a comprehensivemedical cover, whenever they might need health care services, theymight realize that there are no available professionals to assistthem.
Patientshave to face a dilemma due to inadequate resources. They can chooseto wait for days, weeks or even months before their physician isavailable. This waiting period creates several risks like theircondition escalating to the point where it becomes more costly totreat. Other patients are likely to put their lives in a precarioussituation due to the length of time they have to wait before they getmedical care. Some of them may have far more serious illness thatthey cannot waste any time before a physician in their group isavailable. The other option is to find help from a different managedcare system. This move is very expensive since these patients nolonger have the backing of their health insurance. They have to payfor any service that they receive from their very own pocket (Ferlieet al., 2013). The lack of resources does not only relate to theissue of personnel, but it also applies to instruments andmedication. Some sectors of the system of managed care may lack theright equipment that can help solve or cure an ailment which aparticular patient requires.
Thecommon approach is to refer the person to a different facility wherethey can get the service that they need. However, moving from onesystem of managed care to another is a complicated process. Theindividual will likely have to pay the full amount of the care thatthey will receive elsewhere even though their medical cover providedfor that option (Ferlie et al., 2013). This challenge is significantsince it works against the entire concept of the program. Managedcare aims at reducing the cost of healthcare to an individual. Onceseveral sectors under the system have fewer resources or the membersare more than the optimum number, some of the people will still haveto undergo high expenses whenever they need medical services. Anotherissue involves privacy. The entire process of the managed care systemrequires permission from the insurance company before a patient canreceive any treatment. Once the person is treated, the summary oftheir medical records is given to the contractors that manage thehealthcare of the patient (Shi & Singh, 2015).
Thepatients perspective on the quality of care they are given is solelybased on their trust in the qualifications of their physicians.However, there are reported instances where the administration of themanaged care system has offered jobs to individuals that are notcompetent. This strategy has been geared towards saving expenses(Steele & Merrick, 2013). Some patients have not undergoneintensive tests that can correctly establish their illness. Othersick individuals have been taken through unnecessary procedures justso that the administration can show they are using the fundsprovided. Thus, patients feel that the system is financial-based andneglects the core principles of the medical field which is to focuson the needs of the patient. The administration of the same systemview quality of care as a way of showing that the program works.Therefore, if more money is saved while treating patients, theybelieve that the system works (Jung et al., 2015). This skewedperception can lead to the eventual destruction of the managed careprogram.
Thefirst major recommendation is to create a working networking platformbetween the different managed care systems. Patients that requiremore complex treatments should not have to pay from their pockets.Coordination will ensure that even when a person is referred to adifferent physician, they can still enjoy the benefits of theirmedical cover (Ferlie et al., 2013). The sectors that have manymembers should be given a larger portion of the health budget. Thisstrategy will remove the need of people seeking help from otherfacilities since the ones they are enrolled in do not provide whatthey require (Ferlie et al., 2013).
Theissue of quality in the care given has to be firmly supervised. Ifthe federal government includes a body whose objective is to enforcethe standard of treatment that every patient must be given, I believethat more people will be satisfied with the managed care system(Kehoe, 2012).
Epstein,A. M., Jha, A. K., Orav, E. J., Liebman, D. L., Audet, A. M. J.,Zezza, M. A., & Guterman, S. (2014). Analysis of earlyaccountable care organizations defines patient, structural, cost, andquality-of-care characteristics. HealthAffairs, 33(1),95-102.
Ferlie,E., Fitzgerald, L., McGivern, G., Dopson, S., & Bennett, C.(2013). MakingWicked Problems Governable?: the case of managed networks in healthcare.OUP Oxford.
Jung,H. Y., Trivedi, A. N., Grabowski, D. C., & Mor, V. (2015).Integrated Medicare and Medicaid managed care and rehospitalizationof dual eligibles. TheAmerican journal of managed care, 21(10),711.
Kehoe,B. (2012). Keeping score on quality matters. Hospitals& Health Networks, 86(2),30-31.
Shi,L., & Singh, D. A. (2015). Essentialsof the US health care system.Jones & Bartlett Publishers.
Steele,Richard E, MD, MPH, PDC, BCSPHM Merrick, Joav, MD, MMedSc, DMSc.(2013). Managed Care. Journalof Alternative Medicine Research, suppl. Special Issue: Managed carein a public setting,5(4), pgs. 287-289.