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Chapter: Medical Surgical Nursing: Health Care Delivery and Nursing Practice

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Alternative Health Care Delivery Systems - Influences on Health Care Delivery

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).

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).

Managed Care

 

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

 

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.

Health Maintenance Organizations

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.

Preferred Provider Organizations

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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