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Benefits and risks associated with managed care.pdf

Medicaid is the largest healthcare program in the usa

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companies. Medicaid is the largest healthcare program in the USA, at least one in five Americans used Medicaid in 2011, for a minimum of one month. Since the 1990s the share of Medicaid clients who receive managed care increased to 72% in 2009 and continues to grow (source: The Economist, 2011). 4. Main elements of managed care and their application A free choice of health care provider is the norm in Slovakia as is in most of Europe. However, several characteristics of managed care are used around the world, Slovakia being no exception: - Insurers conclude contracts with selected providers, which are compensated with standard fees as well as for fulfilling quality and efficiency criteria agreed upon in advance. - The initial approval of a revision practitioner is necessary for further treatment. - Analyses of health care consumption are carried out. - Generic substitution or prescription is used. - Capitation, i.e. the premium paid to providers is based on the number of those insured rather than on the number of performed treatments. - Emphasis is placed on a transition from in-patient care to single-day out-patient care. - Until April 2011, referral letters from GPs were a requirement for an appointment with a specialist in order to regulate patient s’ access to the provider network (gate-keeping function). While managed care has above all flourished in the USA, another example is the UK’s National Health Service (NHS). It consists of four state companies, integrating health care provision and financing. The UK shows that managed care is not limited to the private sector. The majority of the US population use plans with some elements of managed care. Apart from those mentioned, further practices are typical of managed care: - Managed care and standardized treatment for chronically ill and other seriously ill patients (disease management programs). - Search for high risk individuals among the insured, healthcare consulting and multiple provider coordination in order to avoid complications and serious illnesses (case management). - Higher additional fees for patients who choose expensive treatments when less costly alternatives with similar effects are available and those who select treatment outside their network. - Provider cooperation for better coordinated patient care (e.g. sharing and exchanging health information, diagnostics, treatment and therapy results, planning hospital admission and discharge and patient transfer to after-care).
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10 - Integrating provider and insurer motivation to choose more cost-effective treatments while maintaining a required level of quality and achieving comparable improvements in patient health. - Selecting standard treatments based on analyses of previous treatments and achieved results. - Healthy lifestyle, illness and disease prevention counseling.
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  • Spring '16
  • Health Maintenance Organizations

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