Managed care is a complex system involved in the financing and delivery of health care. The main goals of this system are to control access, quality, and cost of health care. MCOs have complex relationships or contracts with buyers (employers or individuals), providers (health care facilities and physicians), and consumers (patients). To this end, there is a need for complex management structures to organize and oversee these relationships.
There are six different medical management committees typically formed within an MCO. Some serve operational purposes while others serve to meet regulatory and quality standard functions. Refer to the readings of this week and answer the following questions:
Research a Managed Care Organization [MCO] (e.g. Blue Cross Blue Shield, Aetna, Humana, etc.) online. Discuss the similarities and differences between six medical management committees of an MCO.
Analyze the main role of each committee on the basis of your research.
Explain out of the six committees, which committee do you feel is the least important. State your reasoning using specific examples from your research.
In addition, how is the information you found online similar and/or different from what is described in your readings?
After answering the above questions, read the following information:
The development of MCOs has been influenced by the type of market they serve. For example, BCBS companies moved from primarily a service plan provider to a multiproduct line that includes HMO, PPO, and consumer choice plans. In addition, various types of managed care organizations have emerged due to forces imposed by the state and the federal governments, such as the HMO Act of 1973. Answer the following questions keeping in mind the above information:
Examine how public policy has impacted the growth of managed care.
Evaluate the impact of one federal and one state-level policy.
Compare and contrast the ways the policy caused the managed care market to grow or retract.