A system organized to create a balance among the use of health care resources, control of health costs, and enhancement of the quality of care. Managed care systems seek to provide care in the most cost-effective manner by closely monitoring the intensity and duration of treatment as well as the settings in which it is provided. Managed care systems also organize physicians and other providers into coordinated networks of care to ensure that those who enroll in the system receive all medically necessary care. A wide array of mechanisms is used to control utilization and reduce costs. Currently, health maintenance organizations (HMOS) are the most frequently used management system for managed care.
Any arrangement for health care in which someone is interposed between the patient and physician and has authority to place restraints on how and from whom the patient may obtain medical and health services, and what services are to be provided in a given situation. Under the terms of a prepaid health plan, for example, the payer may require: that except in an emergency, a designated person be the patient’s first contact with the health care services; that all care be authorized and coordinated by the gatekeeper rather than permitting the patient to go directly to specialists; that only certain physicians and facilities be used (if the prepayment plan is to pay for the services); that preadmission certification (PAC) precede hospitalization; that second opinions be obtained for elective surgery; and that certain care be delivered in the outpatient setting.
A variety of methods of financing and organizing the delivery of health care in which costs are contained by controlling the provision of benefits and services. Physicians, hospitals, and other health care agencies contract with the system to accept a predetermined monthly payment for providing services to patients enrolled in a managed care plan. Enrollee access to care may be limited to the physicians and other health care providers who are affiliated with the plan. In general, managed care attempts to control costs by overseeing and altering the behavior of their providers. Clinical decision making is influenced by a variety of administrative incentives and constraints. Incentives affect the health care provider’s financial return for professional services. Constraints include specific rules, regulations, practice guidelines, diagnostic and treatment protocols, or algorithms. Care is overseen by quality assurance procedures and utilization reviews.
A form of health insurance in which each member chooses a primary-care physician from a group of physicians who participate in the plan.