Rational of Reimbursement Systems
Introduction
"Managed care was to be the solution to the health care cost crises, a solution that would bring the out-of-control monster under control" (Goff, 1999, p. 25). Mosby's Medical, Nursing, & Allied Health Dictionary defines managed care as "a health care system in which there is administrative control over primary health care services in a medical group practice. Redundant facilities and services are eliminated and costs are reduced. Health education and preventive medicine are emphasized" (1998). Health maintenance organizations (HMO) are traditionally thought of as the original managed care system although most insurance companies now employ many of the concepts of managed care. Managed care concepts have been adopted because to a large degree they work. "Managing, or at least controlling, the process of care delivery has consistently proven to be more cost-effective than the traditional "unmanaged care" approach, which has led America to the most sophisticated and most expensive health care system in the world..." (Goff, 1999, p. 28). Even with the proven successes of managed care, there are problems. These problems range from having a negative impact on the economy to the denial of services to patients.
Strengths
The first managed care plans were started in the 1940s, with the development of several health maintenance organizations like Kaiser Permanente in California and the Group Health Cooperative of Puget Sound. Their purpose was to provide comprehensive health care for a set monthly fee instead of the current fee-for-service model (Cooper & Taylor, 1994, para. 27). In an effort to control the escalating costs of health care, the He ...