Managed Care Organizations



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Legal Issues with MCO Contracting

Legal Issues with Managed Care Organization Contracting By: Julia Divino, Krystal Donaldson, Fathima Fathima, Dan Hoyt, Aaron Lewis, and Lakisha Malloy DeVry University

Introduction 3

Managed Care Organizations 3

MCO Contracts 4

Physicians 5

Physicians Operating in an MCO 5

Contracts 6

Key provisions for providers 7

Benefits of operating within the MCO 7

Disadvantages of operating with the MCO 8

Legal challenges for physicians 8

Patients accessing healthcare 9

Patient’s legal rights 10

Recommendations 11

Implementation 12

Justification 12

Conclusion 13

References: 14


Legal contracts are apart of everyday life and healthcare is no exception. Managed care organization (MCO) use contracts to retain the services of providers for their network. The contracts between providers and MCO’s allow the MCO to regulate and safeguard the relationship and working conditions. The security of a contract allows the MCO to reduce liability on the organization as a whole and it creates stability in the marketplace. Stability is key, because it insures the patient that if they chose a provider in an MCO they know they will be able to use that provider for the duration of their treatment. Lawsuits are not uncommon in MCO, so contracts are used to state each party’s responsibilities and will hold the liability in any malpractice and legal concern. The paper goes on to talk more in depth about the relationships of the three parties involved in the healthcare process MCO’s, providers, and patients, and how those relationship intertwine with contracts and regulations to ensure the safety and well being of all parties involved.

Managed Care Organizations

Managed Care Organizations is a healthcare provider, group, or organization that provides healthcare through a management system of providers. The MCO enters into contractual agreements to provide services with insurers or self-insured employers. The department of consumer and business services certifies the organizations to function in the open marketplace. Physicians, healthcare facilities, or other providers, and any combination of the three can make up the organizations. To better understand the legal issues with managed care organization (MCO) contracting, we have to breakdown the three parties involved in the marketplace. The services provided by the MCO and the providers come with many different and unique legal challenges. The MCO has a contractual legal obligation to the provider and vise versa as well as an obligation to the patient. The providers themselves also have a separate liability to the patients when they assume patient care. The correlation and association with the three parties legal obligations causes a very large strain on how MCO contract providers for their organization.

MCO Contracts

MCO’s tend to have more leverage when it comes to negotiating contracts between themselves and the providers. The MCO has created an organization that could give the providers more reach, recognition, and profit in the local marketplace with little overhead and risk placed on the provider. Providers can gain more leverage by standing out in the marketplace by creating a niche service or an already established network of referrals driving more business their way.

The contracts themselves are heavily one sided towards the MCO’s. The MCO’s make sure the contracts are highly restrictive that offer minimal protections to the providers. The MCO usually institutes reimbursements rates in their favor, a binding arbitration clause making sure the provider cannot air their grievance publicly, and even before that, they make sure the language states the provider has to exhaust all administrative appeals before arbitration. To further complicate the issue, the administrative determinations only have a very short period to offer an appeal to the ruling, further demoralizing the provider into a haste acceptance to the MCO’s ruling.


The growth of Managed care organizations to provide healthcare in United States has generated issues in litigation and new legislation related to problems in the delivery system. Abuses include the gagging of physicians from inappropriate denial of care, false claim data, economic credentialing, financial disincentives, deselecting, insurer insolvency, denial of specialty referral, providing full disclosure of medical options to patients to lack of appeal and render care. These problems have affected patients and damaged patients/physician relationship. The United States healthcare system have placed a large administrative burden on physicians. Doctors who contract with more plans report spending more time in patient care. Contracting opportunities provide significant benefits to physicians. They add costs in terms of time spent outside patient care and lower adequacy time with patients. The expansion of insurance coverage expected through the ACA is believed to be increasing the number of insurers in every state and the availability of contracting opportunities. According to Dan (2014), “Simplifications that reduce the administrative burden of contracting may improve care by optimizing allocation of physician effort.” (p. 237). The development of uniform standards for processing administrative interactions and transmitting claims can reduce the transaction costs of contracting.

Physicians Operating in an MCO

The contract between a physician and managed care organization is a document that states and governs their relationship. Contractual provisions can affect practices and procedures, payment, confidential records, office organization and clinical decision making. Due to the emergence of third-party payers and managed care, new elements are introduced that require complex, structured agreements that states everything from who renders medical services, to what medical services are rendered.


Physician groups and physicians that are contracted with managed care organizations risk exposure to liabilities. Physicians need to broaden their individual insurance coverage to be safe from these liabilities. Integrated delivery systems or IDSs are affiliated entities who help physicians deal with issues regarding insurance. It is very rare that managed care organizations offer help to physicians especially when they have their own personal liability. Many managed care organizations ignore physicians’ interests. During these crises, a broader coverage is needed because of the risks relating to the following issues:

· Changing employment relationships – Physicians who provide health care services in managed care organizations usually move to larger healthcare systems. This gives rise to issue related to tail risk associated with medical malpractice claims.

· Gatekeeper responsibilities – Physicians affiliated with managed care organizations often find themselves in gatekeeper roles. Physicians may make decisions regarding benefit plan design, cost containment decisions and perform administrative tasks.

· Capitated contracts – Managed care organizations are shifting the risk of providing treatment to healthcare providers.

· Contractual liability – Physicians who contract with managed care organizations directly must check that their coverage will apply to liability under the contract. Sadly, many have excluded all coverage for contractual liability.

Key provisions for providers

The provider must investigate the MCO to assess service area, solvency, market share, stability and reputation. Physicians must analyze the terms in the agreement. A provider should limit his obligation to provide covered services to the extent allowed by the provider’s organization. A provider should require MCO to disclose the applicable criteria and incorporate them in the contract. A provider should accept capitation arrangement only when there is reasonable volume of enrollees during the term of the contract. The provider must examine the insurance and indemnification provisions carefully. The provider should sign the contract and accept its terms, only after careful evaluation and review.

Benefits of operating within the MCO

The science of medicine draws strength from many sources and the managed care can help produce better care (Brown, 1998, p. 42). One of the advantages of affiliating with managed care organizations is that physicians can access the organization’s insurance resources and professional risk management. The combination of resources allows the provider to access in real time vital patient information from a centralized database. The access to the electronic medical records database reduces the time and legal liability that often comes with transferring sensitive HIPPA information from one provider to another. The in provider network opens up more possibility to refer patients to receive specific medical treatment outside of their skill set, reducing medical liability to the provider.

Disadvantages of operating with the MCO

Managed care companies drastically cut reimbursements, dictated utilization, cost physicians their patients, and arbitrarily dropped physicians from panels. Physicians work hard, but they earn less in managed care organizations. Sacrificing quality to reduce costs frustrates physicians. According to Vavala (1995), “When a (managed care or insurance) company can tell you when and where to operate, who to see, and what drugs to use, you’re pretty much an employee.” (p. 7). This statement clearly shows how physicians get treated in MCO’s. Participation in managed care affects physicians’ assessment of clinical decision making. Physicians have reported less control over their work schedules and less satisfaction with their salary.

Legal challenges for physicians

There are many different legal issues that physicians might face from managed care contracts. Legal issues can be from the physicians, patients or MCO. Contracts that don’t have enough information and means of avoidance are at a much greater risk for liabilities. Physicians need something to fall back on to, if they were to encounter anything of this sort, litigation would serve a greater purpose for this. Records and confidentiality and denial of treatment are two important challenges that physician’s might face.

Records and confidentiality is very important in managed care contracts. Confidentiality in health care refers to the obligation of professionals who have access to patient records or communication to hold that information in confidence (Prater, 2014). Medical records are the responsibility of the provider and the managed care organization. MCO’s are responsible for maintaining the patient’s records, security, and when to disclose information. The provider has to ensure that they adhere to state and federal regulations; an example of this would be HIPPA. It’s very vital that providers maintain that patient-provider relationship to keep all records and information confidential. It very important who have access to patient medical records, the records and confidentiality clause must state who able to have access of the patient’s information and how long they should have access of these medical records.

Denial of treatment is failure to provide medical treatment to a patient who requires it. Physicians have to be very mindful when doing this, especially when there is an emergency situation. Denial of treatment is considered a breach of contract and can lead to legal disputes. Physician can’t refuse treatment because of their ethnic, racial, or religious background. It’s very important that patients review what physician their seeing ahead of time so they can make sure that their insurance is covered by that particular physician. By doing this, physician won’t have to deny that patient from being seen. Patient’s insurance can be tricky when the patient has an emergency and needs to be seen and their insurance isn’t covered. There are times where people don’t have insurance at all either. When this type of situation arises, it’s important to see the patient regardless of the insurance because if something happens to that patient and the physician failed to administer treatment, that physician will be at fault.

Patients accessing healthcare

Patients in the US have a right to access healthcare without being discriminated against. When it is comes to accessing healthcare, patients have a variety of choices to choose from. Patients first have to decide if they would like insurance. The cost of healthcare in the US is extremely high, so using insurance seems to be the logical choice. Access to a specific provider could be more difficult. If the patient were to have no insurance, they could pretty much chose any provider that will accept them and pay for services rendered. MCO’s also have a pay per service system in which the patient can chose a provider at a higher cost. Another health plan offered by MCO’s is to use providers that are in the provider network, and depending on the size of the MCO could cause issues with using a specific provider and or finding one relative to your location.

Patient’s legal rights

Patients play a very important role in their legal rights in a managed care organization. The doctor is responsible for rendering medical services to the patient according to the community’s standards of practice, and in turn, the patient was responsible for paying the physician’s usual and customary fees (Reuters, 2018). The basic legal relationship in medicine is between the physician and the patient. There are times people have serious medical conditions and have to make drastic medical decisions abruptly. Sometimes these patients aren’t even clear on the information at hand and are very vulnerable at that present time, but a decision must be made. Health care laws allow patients the right to be in control of their care. Patients have the right to have a say of who can get a copy of their medical records with their permission. Providers are required to obtain a patient’s “informed consent” before any treatment. Patients have rights to gain a copy of their medical records and the provider is responsible for keeping them private.

The legal rights between the patient and MCO are also important. Managed care organization means any entity which contracts with the Department to provide services where payment for medical services is made on a capitated basis. This means that patients have the right to be seen for emergency services, emergency medical screening examinations, and post-stabilization medical services. A patient has a right to choose the physician they want, they can request to receive information concerning their condition, they can refuse any treatment to the extent of the law, and the privacy and confidentiality of records. When a bill is released, the patient has a right to receive an explanation of that bill. An individual can purchase any health care service they choose.

A legal recourse is an action that can be taken by an individual or a corporation to attempt to remedy a legal difficulty. A lawsuit if the issue is a matter of civil law. Contracts that require mediation or arbitration before a dispute can go to court (2018, April 10). A lawsuit if the issue is a matter of civil law. Contracts that require mediation or arbitration before a dispute can go to court. There are times patients aren’t pleased with the service/care that was provided by a particular physician. So they go making false accusations to the public to try and bring that physician down. A legal recourse can aid them in situations as such.


The cost of healthcare in the US is high. One of the largest causes of high cost is a preemptive cost increase to preparation of potential litigation. The providers insurance has to charge more because their services could be used in the event of any malpractice cases between provider and patient. In turn the patient has to pay higher cost so the provider can pay their insurance. Because the costs are so high for the patient, they have to obtain insurance for them to get medical treatment at a more reasonable cost. The recommendation of this paper would be to set regulation on litigation in the US in medical malpractice cases. The government could regulate the max financial penalty awarded in the case to ease the burden on insurance, thus allowing them to lower their cost. The trickle down of cost savings could save money for patients, providers, and insurance companies a like. The regulations could go a step further by regulating max cost of procedures and medication as well. Furthermore the government needs to keep a close eye on the power of MCO’s so that they are not able to strong-arm the providers into contracts that unfairly lean in one direction.


The implementation of new regulation in the MCO marketplace would take time and a commitment from congress to bypass the big lobby donors of the MCO’s. The process would have to start with real public discussion on how MCO’s can control the marketplace reducing the competition. The discussion would make congress aware to and thus put more pressure on MCO’s with regulatory agencies already in place. The hands of the regulatory agencies will be tied up in court trying to enforce policy to these large organizations. Because of the legal challenges with taking on large conglomerates, congress will have to make laws protecting arbitration, and one-sided contracting without proper representation.


Healthcare in the US has too much money involved to keep the corporate greed away from taking advantage of legal loopholes. Companies will not negotiate a contract that does them a disservice making it even harder for them to come to an equal agreement. The regulation of how these contracts are set and put in place will do wonders for a fairly young industry to have equal growth and success. Healthcare in the US has forced the government to step in and look after patients and soon if nothing is done about these contracts, it will have to step in and ensure the providers have rights as well.


Healthcare is an industry that is susceptible to fraud; do to the dependent natured relationship between provider and patient. MCO’s contracts between providers and organizations ensure that all parties involved do the necessary requirements to treat a patient. The contracts between MCO and providers tend to lean in favor of the organization. The MCO has more power to demand certain things from the provider, because they have the patient pool that allows the money to flow into the providers. The providers do have rights, but they limit those rights when they sign away key provisions in the contracts. The patients themselves have rights as well, and thru more regulation could have more rights when it comes to litigation with MCO’s and providers.


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Running head: Pros and Cons of Managed Care in America 1

Pros and Cons of Managed Care in America 3

The Pros and Cons of Managed Care in America

Group 2: Mari Copes-Griffin, Melissa Craft, Felicia Cross,

Zandra Custodio, Katarra Davis and Savannah Davis

Professor Richard Barrett

HSM 420

DeVry University

Table of Contents

I. Abstract……………………………………………………….……………………….3

II. Introduction……………………………………………………………………………4

III. Background…………………………………………………………………………….4

IV. Review of the Literature……………………………………………………………….6

a. Pros Associated with Managed Care…………………………………………..6

b. Cons Associated with Managed Care……………………………………….…7

V. Challenges and Problems Associated the Pros and Cons of Managed Care…………..7

VI. Challenges/Problems Analysis…………………………………………………………9

VII. Recommended Solutions……………………………….………….…………………10

VIII. Implementation of Solutions……………………………………….…………………11

IX. Justification……………………………………………………………………………12

X. Summary and Conclusion.…………………………………………………..……….12

XI. References…..………………………………………………………………..………14


Managed care is one of the leading forms of health care in the United States. Health care practitioners, institutions, insurers and patients are working to increase access to health care at a lower cost without sacrificing quality care. This paper reviews the pros and cons of managed care as well as challenges and problems. Recommended solutions to the challenges and problems are also discussed.


Managed health care is a health care insurance method in which patients agree to visit only certain doctors and medical facilities.  One goal is to lower the overall cost of care as a managing company keeps watch on the financial results. This paper examines and analyzes the pros and cons of managed care.

Some of the pros include lower cost, accredited care, cheaper prescriptions, rapidly-moving information within the network, keeping families together, and guarantee of care within the network. The cons that we will discuss are: restricted care, strict approval, referral problems, extremely rigid rules, the necessity for self-advocacy, dollar and cents taking priority over individual needs, loss of privacy, and long wait times.


According to managed care is defined as “a health care delivery system organized to manage cost, utilization, and quality.” The sole purpose of managed care is to provide affordable prepaid health care services to those enrolled who are employees and or beneficiaries who joined a managed care plan. There are three types of managed care plans including: HMOs, PPOs, and POS plans.

As per a Health Maintenance Organization (HMO) is a health care plan that has its own network of doctors, hospitals and other health care providers that agree to take payments at a certain level for the services they provide. HMOs allows its users to reap the benefits of lower cost and the choice of providers. Regarding HMOs you must first select your primary care physician (PCP) who then becomes responsible for all your health care needs and if at any time you need to see a specialist you must first visit with your PCP who must then refer you to a specialist. defines a Preferred Provider Organization (PPO) as a “partnership in which medical professionals and facilities provide services to clients at a reduced rate”. Although the definitions of HMOs and PPOs are very similar there are differences. PPOs offer more flexibility. PPOs allows you to choose from whom you receive care in or out of your network. Although a PPO affords the beneficiary more choices it will also mean higher out of pocket cost.

Point of Service Plan (POS) is defined as a “type of managed care plan that is a hybrid of the HMO and PPO plans” ( With this type of plan a primary care physician is assigned within the network. Patients may seek care outside of the network, but this will mean they must cover the cost on their own unless the primary care physician provides a referral, then their plan will cover the cost.

In the United States the beginnings of managed care can be traced back to the late 19th century. It all began when a small group of physicians throughout different cities within the United States started offering prepaid medical care to unions and other associations. The members of these groups were only required to pay a small annual fee to the physician which allotted them unlimited access to health care services.

During the great depression organizations like lumber, mining and railroad companies began offering their own medical services. By 1973 the HMO Act was passed, which according to Essentials of Managed Health Care “It authorized startup grants and loans and, more importantly, ensured access to the employer-based insurance market.” (p.7) This act provided a financial stepping block for developing HMOs and required that employers must offer their employees the option of coverage from at most one qualified HMO. In the 1980s the prospective payment system which is defined by as “a method of reimbursement in which Medicare payment is made based on a predetermined, fixed amount”, was initiated. Through this system the amount paid was solely based on the classification system of the service rendered.

In the 1990s a capitated agreement, which is a payment of a fixed rate for every patient covered by the plan, was initiated. In 2010 the Affordable Care Act also known as ObamaCare was passed which made affordable health care available to more people, expanded the Medicaid program to cover individuals with an income well below the poverty level in some states and improved the way in which health care was delivered. Today Managed Care has continued to grow and be a fundamental component in the delivery of health care and serves as a facilitator between the provider and the patient.

Review of the Literature

Pros Associated with Managed Care

Managed care is one of the leading forms of health care in the United States. Options available to individuals are preferred provider organization (PPO), health maintenance organizations (HMOs) and point-of-service (POS) plans (Cyrene, 2018) with different co-pays. With managed care less of the health care dollar is spent on prescription drugs. Patients use less expensive, generic drugs for their treatments and see lower costs for their drug co-payments (Jackson). There is also a lower cost associated with health care provided to the members. Health care costs are lower without sacrificing quality.

Another advantage of managed care is the network of readily available health care providers and facilities that have been evaluated and assessed through an accreditation process with denotes that they have met the standards as outlined by the profession (Cyrene, 2018).

Cons Associated with Managed Care

There are also disadvantages to managed care. Patients in some plans can only see a specific health care provider if that provider is within their approved network. Most managed care plans restrict where the patients can go to receive care. If a patient wants to see a provider outside their approved network, they most likely would have to pay out-of-pocket (Jackson). Because most managed care plans place restrictions on where patients can go to receive care, patients who want to see a specific doctor will often have to spend more in out-of-pocket costs to see those physicians. Many patients in a managed care plan complain about the long wait times to get appointments, inconvenient venues for practitioners and that available appointment times are not a good match for their work and family life schedules (Cyrene, 2018).

With managed care providers must take into consideration the patient’s plan before referring to a specialist (Jackson). In managed care what insurance companies are willing to fully or partially cover is very strict. You must speak with an insurance company representative to discuss your issue before you can be approved for treatment. With the strict approval with managed care, approval for pre-existing conditions are often difficult (Vittana, 2018). Patients also do not like their loss of privacy that they often encounter with managed care. Patients dislike the fact that the managed care company receives detailed summaries of treatments, and medical conditions. (Cyrene, 2018).

Challenges and Problems Associated with the Pros and Cons of Managed Care in America

This section discusses the challenges and problems associated with the pros and cons of managed care in America. Since there are no challenges and problems associated with the pros of managed care, the focus of this section is on the challenges and problems associated with the cons of managed care.

Some of the challenges and problems associated with cons in managed care include restricted services, referral issues, strict approvals, loss of privacy and long wait times. In managed care the restriction of services is a big issue. In managed care you can only visit doctors that are within your network and those options are limited. For example, if you aren’t satisfied with the treatment you are getting there may not be another in-network provider that is accessible through your plan and receiving a second opinion outside of your network more than likely will not be covered by your insurance.

In managed care what insurance companies are willing to fully or partially cover is very strict. You must speak with an insurance company representative to discuss your issue before you can be approved for treatment. With the strict approval with managed care, approval for pre-existing conditions are often difficult. A pre-existing condition is a health condition that exists before an individual applies for or enrolls in a health insurance plan. These conditions may include asthma or heart disease and before the Affordable Care Act was passed insurers had the right to deny coverage.

The fear of the loss of privacy is the same in managed care as it would be anywhere else. In managed care during the treatment planning and payment process summaries of an individual’s medical file contains sensitive information. Although there are policies and procedures in place to protect patient information, nothing is full proof and there is no way to validate that someone’s information is completely safe.

The long wait times have increased since the passing of the Affordable Care Act due to increased access to healthcare to millions who were uninsured. Because of the Affordable Care Act more people are visiting doctors and seeking care. The downside is that there are not enough physicians that are within those networks to meet the needs of the number of patients that were coming in. The longer wait times have made it difficult to speak to a doctor or receive regular checkups.

Challenges/Problems Analysis

Typically, the challenges/problems facing health care in the United States can be evaluated since all managed care is not the same. All plans do not offer customers the same opportunity and value for their money. The largest difference exists between the not-for-profit plans and the for-profit plans. In the case of the for-profit plans, about 65-70% of spending goes to actual medical care while the remaining percentages go to marketing expenses (Roberts, 2016). On the contrary, the not-for-profit plan makes a spending of over 90% of the premium income specifically on patient care. This aspect depicts how expensive it has been even with managed care. The for-profit plans minimally focus on making care affordable to most people in the country (Roberts, 2016).

Health care economists have stated that managed care has achieved more than the credit received for it, but it also came with many issues. Future forecasts on the managed care predict significant changes due to the current problems. One of the major problems is the rush, usually by the for-profit, for care without the consent of practitioners or patients (Roberts, 2016). As a result, this care has been priced out of the market. The system is failing because it has become increasingly expensive and bureaucratic. It currently denies care to many people in need. Many Americans are dying young because they can no longer afford care without insurance coverage. The system has caused people to receive less care and face greater restrictions.

Individuals are increasingly becoming less satisfied and spend more on health care than the amount spent by patients in similar economies such as Canada and the United Kingdom among other countries (Roberts, 2016).

Recommended solutions

The healthcare industry has witnessed and endured many opportunities and challenges. However, this industry continues to formulate different strategies and recommendations to implement in hopes to overcome the challenges occurring over time. The first recommendation is to increase the capacity and strength of the health care safety net. To achieve improved access, there must be an increase in the number of health care facilities and practitioners to increase the availability of services to those who disenfranchised (underserved, disadvantaged, geographically isolated, and special needs groups) (HRSA, 2016). One such case happened in Chicago. In this instance there had been one level 1 trauma center located on the west side of Chicago. This was a major issue for this city; given the ongoing violence occurring within Chicago daily. It was stated on the news that countless of gunshot victims died while in route to Northwestern trauma center, coming from the south side of Chicago. To hopefully correct this issue, there has been a new level 1 trauma center built within the University of Chicago emergency department. This made available a trauma center on both the south and west sides of Chicago.

The second recommended solution would be to improve the quality and efficacy of the health care safety net. To accomplish this there must be practical assistance and other support for institutions and practitioners so that persons served by HRSA programs receive quality, comprehensive, family-focused health care across all ages and medical homes (HRSA, 2016). For example, patients may differ by ethnicity, religion, language, etc. One example of quality and efficacy being improved would be to offer a language interpreter. Within various healthcare facilities there are language interpreter machines available for staff and patient use. Having an interpreter breaks the communication barrier allowing staff and patients to have better communication. Another example that improves the quality and efficacy of the safety net is the implementation of the “My Chart” healthcare application. This application allows for patients to access their medical chart as well as communicate with providers.

A third recommended solution would be to increase enrollment in the utilization of health insurance through Medicaid, CHIP and the Health Insurance Marketplace (HRSA, 2016). Usually individuals do not have health coverage due to a lack of financial resources. To improve the health of individuals who did not have health care the Affordable Care Act was passed. The Affordable Care Act created new avenues for customers to apply for and enroll in Medicaid, CHIP and Basic Health Programs.

Implementation of Solutions

To implement the recommended solutions will involve increasing the capacity and strength of the managed care safety net. One way to accomplish this task is to match treatment to the patient needs and predictions rather than using primarily broad generalizations. The capacity and strength of the safety net will also increase if quality and efficiency are improved. The use of technology can improve statistical predictions and ensure greater patient compliance. Simple measures such as using repeated reminder text messages result in fewer missed appointment. The focus should be on “intensity of services” rather than on numbers or profits. Both patients and health care providers should be accountable for improvements. Cost should not be a determining factor in whether critical care is available or administered (Brennan, 2009).

The cost of health care and insurance continues to rise even though the increase has slowed since the implementation of the Affordable Care Act. One way to keep the cost of insurance down is to enroll more individuals, especially young, healthy people. Advertising, incentives, and promotions to employers can help with that increase.


The recommended solutions as stated above are justified because they work together to provide a multifaceted health care paradigm that will result in the delivery of quality patient care. The increase of capacity and strength of the healthcare safety net will increase the number of access points needed for patients as well as facilitate the recruitment of providers in underserved communities to improve their access to care. These recommendations will strengthen healthcare and other networks through policy development and funding to make sure services are delivered effectively.

Improving the quality and efficacy of the healthcare safety net is needed to provide technical support and more to providers and to ensure that those serviced by these programs continue to receive quality care throughout their entire life. The goal is also to work with safety net providers and networks in hopes that they will participate in a value-based payment system.

Lastly, the increase in the enrollment in the utilization of health insurance is important because it will aid those who do not have coverage and help them understand the benefits, primary care and preventive services that will be available to them once they’re covered.

Summary and Conclusion

There have been many changes over time to Managed Care in America. It has been traced to the early nineteenth century where small groups of physicians provided some prepaid medical care to different unions. It has grown from just covering a few unions by different physicians to helping to cover millions of people throughout the United States. With the growth of the economy there has been a tremendous growth in managed care organizations (MCOs). Following all the growth that the MCO has had over the last century, there has been many obstacles and benefits that they have faced.

With managed care there have been different issues such as restricted care, strict approval for services, referral problems, extremely rigid rules, the necessity for self-advocacy, dollar and cents taking priority over individual needs, loss of privacy, and long wait times. There has been a multitude of issues that have been assessed and refined. Focusing on just the disadvantages would not be a best practice. There are also many advantages to in managed care. Lower cost for insurance coverage, accredited care, lower cost prescriptions, rapidly-moving information within the network, keeping families together, and guarantee of care within the network are just a few of the pros that are seen in managed care.

Managed care has faced the obstacles and continues to have a positive future with the implementation of the recommended solutions. With healthcare practitioners, institutions, insurers and patients working together the goal of increasing access to health care at a lower cost and providing quality care will be realized.


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