ALTERNATIVE
HEALTH CARE DELIVERY SYSTEMS
The rising cost of health care over the last few decades has led to the
use of managed health care and alternative health care deliv-ery systems,
including health maintenance organizations (HMOs) and preferred provider
organizations (PPOs).
The PPS has given rise to a much broader pattern of reimbursement and cost control: managed health care. Managed care is an impor-tant trend in health care. The failure of the regulatory efforts of past decades to cut costs and the escalation of health care costs to 15% to 22% of the gross domestic product have prompted business, labor, and government to assume greater control over the financing and delivery of health care. The common features that characterize managed care include prenegotiated payment rates, mandatory pre-certification, utilization review, limited choice of provider, and fixed-price reimbursement. The scope of managed care has ex-panded from inhospital services; to HMOs or variations such as PPOs; to various ambulatory, long-term, and home care services, as well as related diagnostic and therapeutic services. Over time there has been a significant expansion of managed health care to the point that distinctions among different providers—including HMOs, PPOs, exclusive provider arrangements, managed indemnity plans, and self-insured managed care—are blurring.
Managed care has
contributed to a dramatic reduction in in-patient hospital days, continuing
expansion of ambulatory care, fierce competition, and marketing strategies that
appeal to con-sumers as well as to insurers and regulators. Hospitals are faced
with declining revenues, a declining number of patients, more se-verely ill
patients with shorter lengths of stay, and a need to in-corporate
cost-effective outpatient or ambulatory care services. As patients return to
the community, they have more health care needs, many of which are complex. The
demand for home care and community-based services is escalating. Despite their
suc-cesses, managed care organizations are faced with the challenge of
providing quality services under even greater resource constraints. Case
management is the methodology used by many organiza-tions to meet this
challenge.
Case management has
become a prominent method for coordi-nating health care services to ensure
cost-effectiveness, account-ability, and quality care. The case management
process dates back to the public health programs of the early 1900s, in which
public health nursing played a dominant role. Over the years, the process has
varied in form and function, but the basic theme has re-mained. The premise of
case management is that the responsibil-ity for meeting patient needs rests
with one individual or team whose goals are to provide the patient and family
with access to re-quired services, to ensure coordination of these services,
and to evaluate how effectively these services are delivered.
The reasons case
management has gained such prominence can be traced to the decreased cost of
care associated with de-creased length of hospital stay, coupled with rapid and
frequent interunit transfers from specialty to standard care units. The case
manager role, instead of focusing on direct patient care, focuses on managing
the care of an entire caseload of patients and col-laborating with the nurses
and other health care personnel who care for the patients. In most instances,
the caseload is limited in scope to patients with similar diagnoses, needs, and
therapies, and the case managers function across units. They are experts in
their specialty areas and coordinate the inpatient and outpatient ser-vices
needed by patients. The goals of this coordination include quality,
appropriateness, and timeliness of services as well as cost reduction. The case
manager follows the patient throughout hos-pitalization and at home after
discharge in an effort to promote coordination of health care services that
will avert or delay rehos-pitalization. Evidence-based pathways or similar
plans are often used in care management of similar patient populations.
HMOs are prepaid, group
health practice systems designed to de-liver comprehensive health care services
to a defined group of vol-untarily enrolled individuals. Members pay premiums
as well as designated copayments for services and medications. Individuals
receive care from a preselected group of physicians, nurse practi-tioners
(NPs), or other care provider members of the HMO, al-though some programs allow
selection of outside providers for a higher fee. HMOs are based on the holistic
concept of care. They provide outpatient (ambulatory) and preventive teaching
and health care, as well as inpatient care that meets the health care needs of
the whole person. The goal of HMOs is to give com-prehensive health care that
is of the best quality and quantity for the money available, while eliminating
fragmentation and duplication of services. As HMOs have grown, they have
ex-panded to include specialist services and programs for Medicare and Medicaid
populations. Some studies show that HMOs are cost-effective and that the
quality of care provided by these health care delivery systems is comparable to
that provided elsewhere in the same communities. However, concerns have
surfaced re-garding the limitations on choice of health care provider,
diag-nostic testing, and length of hospitalization; high case loads; and
problematic paperwork that might be imposed by some HMOs (Cesta & Falter,
1999). To address these concerns, some employer and federal health insurance
providers offer alternative plans to HMOs.
HMOs have paved the way
and served as the model for private fee-for-service (FFS) organizations that
offer some choice to con-sumers. PPOs, point of service (POS) plans, provider
service organizations (PSOs), Medicare+Choice
plans, and coordinated care plans are some examples of variations on the HMO.
These plans allow consumers, including Medicare beneficiaries, to choose their
hospitals and physicians and allow providers to be reimbursed on an FFS basis.
In contrast to the HMO,
the PPO, POS, or similar organiza-tion is not a distinct entity; rather, it is
a business arrangement between a group of providers, usually hospitals and
physicians, who contract to provide health care to subscribers, usually
busi-nesses, for a negotiated fee that often is discounted. Organizations like
PPOs allow businesses to decrease their expenses for em-ployee health care
benefits, and hospitals and physicians to mar-ket their services to employers.
Some advanced practice
nurses serve as preferred providers through nursing centers or in individual or
joint practice. Ad-vanced practice nurses provide health care delivery that is
unique, client-based, and holistic. These nurses often provide care to
vul-nerable populations, allowing direct access to nursing services. In nursing
centers, nurses provide the majority of services, control the budget, and
function as chief executive officers. The role of many advanced practice nurses
emphasizes primary care with col-laborative, interdisciplinary models of
practice.
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