Case Study: Managed Care Organizations

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Case Study: Managed Care Organizations

Case Study: Managed Care Organizations

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The differences and similarities between Managed Care Organizations (MCO) and Accountable Care Organizations (ACO) will be explained below.

The MCO is a group of medical providers and facilities that provide care to its members at a reduced cost. Many MCO’s require the patient to have a primary care provider. The ACO is a group of medical providers and medical facilities that work together to provider collaborative care to its members. The ACO doesn’t require the member to have a primary care provider.    The providers work together voluntarily to provider care as a medical team for the patient. The different specialties work with each other to treat the patient with continuity of care. The information is shared so that all the providers that are treating the patient are aware of the medications, tests, hospital visits, and treatment the patient has currently and the past treatments. The providers that are part of the MCO’s don’t work as a team to provider collaborative care to the patients. They don’t strive to work together to treat the patient with the team approach like providers in the ACO’s strive for. The MCO groups can share information if it is requested. The focus is not continuity of care.  Some providers send their notes to the referring provider as a courtesy.  The ACO’s are still changing to become better.  The MCO’s and ACO’s may transform and merge into one entity to meet the needs of consumers. They both are similar enough to the point where I think they can be combined with the best interest of the consumer in mind. I believe that we can take the best features from both of them. Considering the current health care environment , continuity of care is important. This is the best way to treat the patient with the best possible outcome. Having the providers work together as a team avoids having the patient take medications that interact, repeating the same tests, and other wasteful or harmful medical practice. This approach can also reduce the cost of medical care. The cost of medical care is constantly increasing and I think this is a way to reduce the cost of medical care. This will help control wasteful spending.

 

“Managed Care.” MedlinePlus, U.S. National Library of Medicine, 25 Sept. 2017, medlineplus.gov/managedcare.html.

 

“What Is an ACO? Definitive Guide: Accountable Care Organizations.” Health Catalyst, Health Catalyst, 24 Oct. 2017, www.healthcatalyst.com/what-is-an-ACO-definitive-guide-accountable-care-organizations.

Student 2 Kpanbu

Health care spending is the biggest drive for formulating the different kinds of payment systems in healthcare. Health care insurance enrollees may obtain care from various Managed Care Organizations (MCOs) or Accountable Care Organizations (ACOs).

Managed Care Organizations (MCOs): is a group of people working together to manage the cost of health care.  MCOs work along with medical facilities and health care providers to render support to MCO patients. MCOs only pays for the care provided and its plan is not as flexible as ACOs. MCOs give incentives to physicians like the ACOs. There are four types of MCOs: Health Maintenance Organization (HMO), Preferred Provider Organization (PPO), Exclusive Provider Organization (EPO), and Point-of-Service Plan (POS).  According to (Andrews, 2014), HMOs only pay within network health care and insurers need a referral to seek care from a specialist or else the services provider will not be covered. For PPOs, care is covered both in and out of the network, however; the patient pays a higher premium for out of network care.  In EPO, care is not covered outside of the network, nevertheless; patients do not require referral to get seen by a specialist.  In POS, plan varies between HMOs and PPOs, and insurers may seek out of network care but with a higher cost-sharing rate. PPO and HMO both have Medicare options.

Accountable Care Organizations (ACOs): is a number of individuals that consist of health care providers and health care settings, collectively working together to accomplish the goal of improving optimum quality of health care. This network of people may include physicians, surgeons, pharmacists, doctors, nurses, healthcare assistants, caregivers, lab specialists, psychiatrists, mental health professionals, rehabilitation workers, other healthcare specialties and hospitals. This group of people collaboratively work together to coordinate patient care to obtain maximum care for clients and the group “accepts joint responsibility for health care spending and quality for a defined population of patients” (Song, 2014).  According to Song (2014), the three key characteristics of the ACO are: “joint accountability,” accountability for both quality of care and health care spending, and the ACO is responsible for the care of a population of people.” In the ACO plan patients have more freedom to choose the type of care within a restricted time period.  ACO provides a variety of payment structures and incentives to health care providers and hospitals primarily focusing on quality of care and financial risks to hospitals and physicians. ACO reward health care providers for the quality of care provided to patients, while eliminating irrelevant spending. ACOs do not focus on profit, but the quality of care while MCOs focus on profit.

References:

Andrews, M. (2014). What’s the best health plan for you? HMO, PPO, EPO or POS? Retrieved from  https://www.washingtonpost.com/national/health-science/whats-the-best-health-plan-for-you-hmo-ppo-epo-or-pos/2014/08/25/772f96a8-27c1-11e4-958c-268a320a60ce_story.html?utm_term=.51bd23ba540e

Humana. (n.d.). HMO vs. PPO: Which one is right for you? Retrieved from  https://www.humana.com/all-products/understanding-insurance/hmo-vs-ppo

Song, Z. (2014). Accountable Care Organizations in the U.S. Health Care System. J Clin Outcomes Manag. 2014 Aug 1; 21(8): 364–371.

Case Study: Managed Care Organizations

 

Student 3 Talisha

An MCO is a type of health care system that links health insurance with care delivery for a defined population. An MCO delivers health care through a network of providers, determines the prices for services, coordinates care, and manages appropriate use of health care services. According to the National Accountable Care Organization Summit (n.d.), ACOs are provider collaborations that support the integration of groups of physicians, hospitals, and other providers in different ways around the opportunity to receive additional payments by achieving continually advancing patient-focused quality targets and demonstrating real reductions in overall spending growth for their defined patient population. According to Shortell, Casalino, and Fisher (2010), there are at least five different types of practice arrangements that could serve as ACOs: the integrated or organized delivery system, multispecialty group practices, physician-hospital organizations, independent practice associations, and “virtual” physician organizations. The Accountable Care Model (ACO), the health care providers develop and drive the models’ respective agendas (McWilliams et al., 2016).

Given the similarities seen between MCOs and ACOs it is clear that MCOs have a more monopoly set up on their delivery method of care; while ACOs allows for free movement outside or within their integrated networks. Centers for Medicare and Medicaid Services (2015) states that participation in ACO is voluntary. This implies that the patient consumers have the freedom to select the Primary Care Physician of their choice, the hospitals they want and their favorable specialist. Given the current healthcare environment over time MCOs and ACOs can evolve into more organized networks of practices that will actively engage in practice redesign, quality improvement initiatives, and implementation of much more innovate technologies moving forward, for example one of their noteworthy success has been the implementation of electronic health records. The Electronic Health Records (EHRs) are now giving doctors and physicians real time secure access to patients records to better assist them across both MCO and ACO networks alike, saving time, money and creating more vital time providing much needed focused patient care.

Reference

Centers for Medicare and Medicaid Services. (2015). Accountable care organizations (ACO). (n.d.). Retrieved from http://www. cms. gov/Medicare/Medicare-Fee-for-Service-Payment/ACO/index. html.

National Accountable Care Organization Summit. (n.d.). What is an ACO? Retrieved from http://www.acosummit.com/past2011/overview.html

Shortell, S. M., Casalino, L. P. & Fisher. E. S. (2010). How the Center for Medicare and Medicaid Innovation Should Test Accountable Care Organizations. Health Affairs, 29 (7), 1293-1298.
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