What Is the Role of Managed Care in Value-Based Care

Role of Managed Care in Value-Based Care

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Let’s look at managed care in more detail and the importance of care management.

Managed care is a healthcare financing and delivery system in the United States. You might be connected to specific providers and medical facilities if you are a health insurance plan member.

A managed care plan, commonly known as a managed care organization, is a company that manages care and expenditures for its beneficiaries. A managed care plan strives to keep costs down while guaranteeing that beneficiaries have access to a provider network and receive excellent care. By focusing on care management and prevention, the goal is to provide better care for its customers.

The managed care approach has existed for decades, with significant development since the early 1970s and the Health Maintenance Organization Act. Over the years, managed care plans have evolved from a narrow focus on costs and utilization to more comprehensive preventive health, population health, and Care Management approaches.

Let’s discuss the importance of Care Management and the nuances of managed care.

What Is Managed Care?

Managed care plans are health insurance plans that focus on managing care for enrollees in order to minimize costs and keep the quality of care high. Managed care plans are available across Medicaid, Medicare, and commercial markets. United HealthCare, Anthem, and Humana are among the most well-known examples.

With What organizations does a managed care plan work? With respect to funding, managed care plans contract with payers seeking coverage for individuals, such as the federal Medicare program, state Medicaid programs, and private employers. Concerning payment, managed care plans contract directly with providers, health systems, and other organizations to provide services to covered enrollees.

Medicaid and the Children’s Health Insurance Program (CHIP) are heavily guided by managed care. More than 70 million individuals in the United States receive health care coverage through Medicaid and CHIP. States determine Medicaid eligibility requirements. Persons with disabilities or low incomes are usually eligible for Medicaid.

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As of 2013, 41 state Medicaid programs contracted with managed care firms to provide care to Medicaid beneficiaries. Many of these arrangements focus on mainstream managed care, which provides services and benefits for the general Medicaid population. Medicaid-managed care organizations contract with states to cover the healthcare needs of Medicaid patients and must adhere to state-specified eligibility and coverage requirements. Managed care has become a standard part of state Medicaid programs to control costs, benefits, and quality of care. Working care continues to evolve in Medicaid programs.

Some states use these programs to target populations with chronic or complex conditions. These programs generally emphasize care coordination and integration programs to give their populace access to a more extensive range of services to manage their needs. Managed care plans are an essential component of these programs, coordinating benefits for these individuals.

States also focus on value-based initiatives for mainstream and specialty managed care programs. Value-based initiatives link payment incentives for managed care plans and providers—they link payment to specific healthcare outcomes, patient experience objectives, and eliminating unnecessary care.

Managed Care Plans Consist Of Several Types.

An outline of the most common managed care plans is provided below.

  1. Health Maintenance Organizations (HMOs). 

HMOs frequently have lower monthly premiums and manage care by restricting enrollees to seeing certain providers. In-network providers are those contracted directly with the plan (non-network providers are referred to as out-of-network providers). An HMO may also require enrollees to see their primary care doctor and obtain a referral before seeing a specialist. Preventive care appointments, such as yearly wellness appointments, are fully covered. HMOs are often less expensive but offer fewer choices than other options.

  1. PPOs are Preferred Provider Organizations.
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Preferable Provider Organizations (PPOs) have larger provider networks and offer enrollees more flexibility, but they tend to be more expensive. In a PPO, beneficiaries can see either in-network or out-of-network providers. A PPO’s preferred provider network provides in-network care at a lower cost than an HMO. Because beneficiaries can visit any provider, monthly premiums for PPOs are typically higher than those for HMOs. As a consequence, preventive care is provided at 100% in PPOs.

  1. Point of Service Organizations (PSOs)

Among other things, POS plans are a blend of the HMO and PPO designs. POS plans allow you to see in-network or out-of-network providers, but you pay higher costs. You might require a referral from your primary care physician before seeing a specialist if you have a POS plan. Enrollees must pay more to see out-of-network providers unless their primary care provider makes a direct referral. POS plans provide patients with flexibility and choice while reducing costs and utilization.

  1. Exclusive Provider Organization (EPO).

EPOs typically offer a local network of providers and hospitals for enrollees to choose from and tend to be less expensive than PPO plans. Emergency care is the only exception to out-of-network care not being covered. When considering EPO premiums, enrollees should be aware of the importance of seeking in-network care.

Managed Care Organizations Reap the Benefits of Care Management.

In spite of everything, the goal of managed care is to focus on prevention and long-term health outcomes. Care management and preventive care can accomplish those objectives.

Managed care organizations are responsible for administering health plan coverage, engaging with enrollees, managing utilization of services, maintaining strong provider networks, controlling costs, and delivering quality care. Using a Care Management approach saves managed care plans time and resources, improves patient care and outcomes, and minimizes the need for avoidable costs and services. Care Management comprises activities and interventions aimed at improving care quality and coordination. Patients and their families are supported in caring for their health problems as part of Care Management. Care Management also aims to prevent duplication and support patients and their families in managing their health issues.

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A care management approach employed by a managed care system could identify a “hole” in care or a difference between recommended treatment and genuine care. For example, a 56-year-old woman with a cancer history may not have received her yearly mammogram. The health insurance company will contact her primary care doctor and a care coordinator to inform her of this. The care coordinator will organize an appointment at a nearby imaging center, ask Diane if she has any problems traveling to it, and reply to her queries.

The health insurance plan’s Care Management approach identified a need, engaged with the patient, and intervened to make a connection to caring. Connecting to caring and improving patient outcomes directly related to their specific needs are aligned with achieving access to care.

An Effectively Managed Care Program Can be Achieved Using a Care Management Platform.

A Care Management platform is compatible with the objectives of managed care programs and providers. A Care Management solution enables care teams and physicians to communicate effectively, comprehend patient needs, and cooperate with managed care programs for both individual and population-wide care by connecting to a care management platform.

Ensuring quality care, engaging with enrollees, and controlling healthcare costs under managed care depends on clear and comprehensive communication and data sharing. To find out how a Care Management platform like Hucu.ai works and how it can help you reimagine managed care, visit the how it works page.

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