Managed Care Plans in the US: Diff & Sim, Access, & Delivery - Essay Sample

Introduction

The managed care plans within the United States have differences and similarities. The system involves the healthcare organizations, the insurance companies, as well as the billing system. The plans available in the state include the Health Management Organizations, the Service on Point plan, Exclusive Provider Organizations, and Preferred Provider Organizations. All these plans serve the citizens using different strategies, access, and delivery of services. Thus, through the nature of the services offered in these plans, similarities and differences are depicted.

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Health Management Organizations (HMO) provides insurances for health and wellness bills to its customers. The coverage is up to a month or sometimes a year, depending on the preferences of the clients. It restricts the customers to the services provided by the HMO specialists hired for the contract. Therefore, it minimizes the cost of health and wellness services and products obtained from the specific clinics and healthcare systems. The network is majorly involved in taking care of the people's needs through an interactive system that ensures correct and efficient information transmission techniques and manipulation of data.

The Preferred Provider Organization (PPO) is another insurance plan that ensures the delivery of health services depending on the preferred institution by the patients. It works on the basis that the existing professional within the institutions and healthcare systems contact the insurance provider to subscribe to the patient for their services. Also, these services are done at a reduced rate to promote the availability of the service. The insurance entails a negotiation between the service providers with the insurance companies on matters concerning the medical fees for their clients (Bai, 2018). Also, the service is made available not only to people registered for the plan but also to none registered members.

The Point of Service plan (POS) is another type of managed care insurance method that can be used within the United States. It is a combination of both the Health Management Organizations plan and the Preferred Provider Organization. The plan implements the HMO methods of providing services within the registered network, with the availability of ceremonies at a reduced cost. Also, just like a PPO, the plan allows the customers to acquire services from a different network. These factors depend on the urgency and preference of services by the client, depending on the prevailing circumstance.

Another plan used within the country included Exclusive Provider Organization (EPO), whereby the citizens can get their medical bills covered by the insurance plan. It operates just like the HMO plan, which only entails serving the people registered within the network. Members of this plan are not guaranteed benefits from other medical insurance plans. Therefore, the system is suited for citizens who do not need greater medical deals. Also, it does not involve referring people to specialists and service providers. Therefore, it makes the process fast and accessible to its clients across the nation.

The primary point to note about these plans is that they all have an advantage in managing the hospital bills. Also, it makes the healthcare services within the country affordable and easily accessible to the customers. Therefore, all the plans ensure than the management plan guarantee the citizens reduced rates in that the savings are used to pay up for the services. Also, the health network has the chance to gain income due to continuing clients streaming in the system. Moreover, it benefits the citizens in that it reduces the chances of walking around with files and papers about their medical bills and services received (Artiga, 2019). The process is taken up by the billing systems in conjunction with the insurance and healthcare organizations.

These plans share various similarities in their service delivery methods. All the managed medical care makes specific arrangements with particular practitioners to come up with techniques and ways of delivering health services to all the enrolled citizens. This is whereby the plans give the clients chances to be part of any of the plans within the state. Therefore, all citizens have a chance of having financial coverage from the chosen plan. Also, service delivery is the same for all people across the plans. In addition, the plans aim at making medical bills affordable and manageable to all citizens in the United States.

Besides, all the managed care plans have a defined criterion and set of standards that are used when selecting the practitioners. This is whereby it assesses the ability of the citizens to pay their bills. Also, other factors such as the person's health issues and their medical requirements. Thus, it registers the person depending on these needs to ensure that the services provided are relevant and helpful to the citizen (Appukkuttan, 2019). For instance, the clients who require immediate and fast responses, a plan such as the Point of Service plan is helpful to the individual.

Furthermore, the medical care plans have formal programs entitled to the currently prevailing quality of services and strategies for ensuring that it remains at its best. Also, other factors such as quality improvements, use, and importance is an essential factor among the plans. This is whereby the involved parties ensure that service delivery meets the required standards. As a result, it reduces the number of deaths and readmission within the healthcare systems. Moreover, the plans advocate for the assurance of excellent services by training its service providers and other involved personnel, and in turn, the citizens within the state are served rightfully.

Additionally, the plans have a financial incentive for all the clients to use the plans and follow the procedures as they prefer. This concept entails the fact that all members are entitled to utilize their medical savings through insurance plans. The plans cover all the mental bills of victims despite comprising the most significant number of people with medical needs. Therefore, strategies have been put in place by these insurance companies to cover the long term needs of such patients. Also, other factors, such as treatments are controlled to deliver quality services and evade issues such as undertreatment (Guercio, 2019).

On the other hand, there are differences depicted by these managed care plans. The healthcare plans within the United States vary according to the nature of services offered. These differences arise due to the cost of delivering services to citizens. Moreover, the disputes occur due to the referrals required to get a chance to be served. Also, the claims forum differs among the plans. Besides, the coverage of clients seeking services out of the network is another matter under consideration. These factors differentiate the plans, thus making the citizens choose their strategies depending on their needs and financial stability.

In terms of cost and affordability, Health Management Organizations are always ranked as the cheapest plan, thus rendering the services affordable to the citizens. In the middle, there is the Preferred Provider Organization that is less affordable than HMO. Then the most expensive health care plan is the Point of Service method. On the other hand, the EPO plan, it is affordable; however, seeking services outside the network could be very expensive for the client. Therefore, the citizens should be aware of the health insurance claim denials during such cases.

Moreover, in terms of choice of providers, factors such as the Primary Care Provided are put into consideration. This is whereby the citizens choose the plan according to how the insurance company coordinates with the healthcare providers. The specialty services render the service delivery easy and quick to the clients. The HMO and SPO have the PCP. However, EPO and PPO do not have the service specialty. Therefore, most citizens prefer the easier methods of accessing the services from the healthcare with the coverage from the insurance companies through the health care plans (Abraham, 2019).

Also, in cases involving the delivery of services, the clients should check on the referrals and chances of receiving care outside the network. This is whereby the HMO insurance plans require referrals for the clients to access the services. On the other hand, the PPO, SPO, and EPO do not require referrals. Moreover, in cases of accessing services outside the network, the HMO and EPO do not allow their registered members to receive medical services outside the network. However, the PPO and POS plans allow access to services outside, however, they are very costly to the clients (Polsky, 2017).

Conclusion

In conclusion, the managed care plans within the United States include the Health Management Organizations, the Exclusive Providers Organization, the Service on Point as well as the Preferred Provider Organizations. These health care insurance plans have their similarities like their services, which include guaranteeing the citizens the chances to acquire affordable and effective medical payment methods. Also, these plans have differences, such as others require referrals while others do not. Besides, other programs allow access to services outside the network, and others deny these opportunities. Thus, the clients choose their preferred methodologies depending on the urgency of the coverage as well as the situation undercover.

References

Abraham, J. M., Royalty, A. B., & Drake, C. (2019). Plan choice and affordability in the individual and small-group markets: policy and performance-past and present. Health Affairs, 38(4), 675-683.

Appukkuttan, S., Tangirala, K., Babajanyan, S., Wen, L., Simmons, S., & Shore, N. (2019). A retrospective claims analysis of advanced prostate cancer costs and resource use. PharmacoEconomics-open, 1-9.

Artiga, S., Hinton, E., & Henry J Kaiser Family Foundation. (2019). Beyond health care: the role of social determinants in promoting health and health equity. Health, 20, 10.

Bai, G., & Anderson, G. F. (2018). Market power: price variation among commercial insurers for hospital services. Health Affairs, 37(10), 1615-1622.

Guercio, C., Patil, D., & Mehta, A. (2019). Hypogonadism is independently associated with varicocele repair in a contemporary cohort of men in the USA. Asian journal of andrology, 21(1), 45.

Polsky, D., Weiner, J., & Zhang, Y. (2017). Narrow networks on the individual marketplace in 2017. LDI issue brief, 21(8), 1-6.