Managed Care

[shabbychic23]

Can someone explain what is managed care?

[PhilaGuy]

I can try to explain it more from the insurance side of things (looking to become a nurse eventually). Managed care or HMOs (Health Management Organizations) are structured health insurance programs. The way they work is requiring you as a patient to see your primary doctor for all non-emergency care as a first step (rather than letting you go to a more expensive specialist, or requesting a test). This reduces costs as many issues can be treated via this primary level of care.

In addition, costs down to the smallest minutiae are figured out for most procedures and dx's. These are negotiated with the various doctors, hospitals, etc. so that actuaries can make determinations on costs for the member groups (and thereby charge back via premiums).

The concept is to reduce costs for the members by controlling and optimizing care. Many times it works, but many times it also can be abused and bring a reduction in care (such as if your primary doctor doesn't ask for a test that they should due to costs, etc. or if a patient doesnt receive follow up because the steps / procedures were too cumbersome).

[pagandeva2000, LPN]

I think that they have become healthcare's nightmare, based on what PhliaGuy's description. I can understand cutting the costs of unnecessary care, however, they have hindered timely treatment with all of the red tape it takes for both, the patient as well as the provider. It seems that unlicensed personnel is making the decisions more than the doctors, which ultimately frustrates many of them.