Managed care organizations and integrated health care networks

  Topic 5 DQ 1

The 2010 enactment of the Affordable Care Act (ACA) brought significant reform to the US healthcare system, including the largest expansion of medical coverage since the creation of Medicare and Medicaid more than 50 years ago. Today, 52 million people 65 years of age and older have a preexisting condition that could have been a deniable condition in the pre-ACA individual market.

There are two major reform factors that have to improve the quality of the health care and the health care system in general.

  • Aligning Payment Policies with Quality Improvement.

Payment policies are a strong influence on how healthcare organizations and professionals deliver care and how patients select and use that care. Value-based payment strives to promote the best care at the lowest cost, allowing patients to receive higher-value, higher quality care. Payment reform, with the goals of shifting provider payments and incentives from volume to value. Payment and delivery reform, alongside related legislative and regulatory changes, has the potential to make transformative models of health care delivery more sustainable, with the promise of better outcomes, lower costs, and more support for investment in new treatments that are truly valuable.

The goal of this reform is to increase the patient satisfaction and decrease the cost of the care. The hospitals that are providing the best care and better patient satisfactions are getting more finance and getting better benefits.

  • Bundled Payment Programs.

Traditionally, Medicare makes separate payments to providers for each of the individual services they furnish to beneficiaries for a single illness or course of treatment. This approach can result in fragmented care with minimal coordination across providers and health care settings. Payment rewards the quantity of services offered by providers rather than the quality of care furnished. Research has shown that bundled payments can align incentives for providers – hospitals, post-acute care providers, physicians, and other practitioners – allowing them to work closely together across all specialties and settings.

This reform started in 2009 and definitely already has a lot of improvements in the health care system. The bundled payments are most commonly used to cost-effectively manage a patient’s care in the hospital and over the following 90 days post-discharge (Haas, 2021). The Centers for Medicare and Medicaid Services (CMS) already wants to make bundled payments mandatory in a few years. This shows that a bundled payment method is more effective for Healthcare organizations and patients as well.

Healthcare organizations are actively involved in the administrative role of implementing risk management regulations and policies, as well as in ensuring adherence to standards set by MCO. Regulatory decrees of the MCO play an important role in enabling healthcare organizations to provide safe and high-quality care, as well as cost-effective care. Managed care organizations influence healthcare in all aspects of delivery. Managed care organizations have shown to improve outcomes, which has contributed to their expansion.

MCO have to work closely with an interprofessional team and understand how to balance the best treatment with great patient satisfaction, and reimbursements to continue providing healthcare at a reasonable cost. This is not an easy task, but I believe that it can be done with the right goals and right healthcare reforms.

 Health care organizations continually face challenges from various regulatory and government agencies while also being bound by Managed Care Organization (MCO) standards. View the video located in the study materials entitled “College of Nursing and Health Care Professions: Do We Know What Our Future Is?” for insight into the challenges of health care reform. Based on the video, describe two key reform factors that you believe will need to be addressed by future health care workers or leaders and explain why. (Note: You can download slides from this video for ease of review in developing your forum response). Additionally, what role does adherence to MCO standards play in your future health care vision? 

  

Using 200-300 words APA format with at least two references. Sources must be published within the last 5 years. There should be a mix between research and your reflections. Add critical thinking in the posts along with research. Apply the material in a substantial way.

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