Outcomes of Managed Care

MCOs and Controlling Costs MCOs do so by controlling 1)MDs 2)Patients 3)Health Care Institutions

Managed Care Controls Costs by Controlling MDs Behaviors 1. Specialists i. In HMOs, patient needs a referral by a PCP ii. Reimbursed via capitation/or discounted fee 2. Utilization Management- MCOs monitor what resources doctors use—too much expenditure, you’ll hear about it 3. Quality Assurance- doctors are monitored for how well they do. Patient satisfaction surveys are common ways of evaluating doctors. 4. Bonuses- doctors may be given bonuses if they do a good job for their work or for saving money (not using too much resources)

Managed Care Controls Costs by Controlling Patients Permission from MD or gatekeeper (HMO) to get treatment Co-payments Deductibles Nurse phone service (prevent access to care) Need approval for experimental or expensive Rx Follow rules of MCO’s plan or you will pay

Managed Care Controls Costs by Controlling Institutions 1.For some providers, capitation 2.DRGs: one fee for everything 3.Accountability-audits are done to evaluate quality of care 4.Performance Evaluation- patient satisfaction surveys

Studies have shown some outcomes on Managed Care 1. PPOs don’t save money 2. HMOs do save money 3. Patient satisfaction survey results show consumers: i. Don’t like bureaucracy ii. Like low costs for HMOs (compared to PPOs) iii. Don’t like the idea that MCOs can deny essential care 4. Public outcry about managed care has caused lawmakers to write laws to protect the consumer.

Studies have shown some outcomes on Managed Care 5. Health outcomes: i. basically managed care and “fee for service” (FFS) are comparable in terms of health outcomes. ii. In some studies, managed care patients do better

Patients Satisfaction One 1997 national survey reported 79% of PPO members, 83% of HMO members, and 81% of POS members were satisfied with their health plan compared to 75% of fee-for-service members.

Patients Satisfaction % of Enrollment Plan Type FFS26%9% HMO33%28% PPO25%38% POS16%25% KPMG Peat Marwick, Health Benefits in 1996 Kaiser Family Foundation & Health Research Education Trust, 1999 annual survey

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