Health Care Reform
Several years ago, health care reform was a hot political topic with President Bill Clinton's proposals to revolutionize medical health insurance. Even though his proposals didn't become law, sweeping changes are occurring within the health care system, particularly in regards to managed care health insurance and the reengineering of the hospital. The goals of these changes are to cut medical costs, make the delivery of health care more efficient, and to promote preventive medicine, health, and primary care. While these changes are positive in many ways, they are also creating concerns among both the health care consumer and provider. These changes must be managed to insure that high quality care remains at the forefront of medical care.
MANAGED CARE HEALTH INSURANCE
GROWTH AND DEVELOPMENT
Managed care plans are the fastest growing form of health insurance (Whigham-Desir, 1996). Sarah Glazer (1996) describes the concept of managed care: "The underlying principle of managed care is to keep the entire community healthy by providing preventive care, such as immunizations and mammograms, at little or no cost. In exchange for lower premiums, copayments and deductibles, the consumer agrees to see a limited group of physicians selected by the plan. The plan keeps costs down by limiting the consumer's access to expensive specialists and procedures." Since three-fourths of Americans receive health insurance through their employer, managed care plans are becoming increasingly popular as both employer and employee seek to decrease medical care costs (Whigham-Desir, 1996).
Managed care has been around since the 1930s when HMOs were formed to promote preventive medicine among doctors (Spragins, 1996). In the 1970s, the federal government encouraged the formation of HMOs to control rising hospital costs (Glazer, 1996). In the late 1980s, costs skyrocketed, and in 1988, employers' health benefit costs rose a record 18.6 percent (Glazer, 1996). As a result, managed care began to take root, and by 1993, a majority of employees were covered by managed care (Glazer, 1996). With medical costs approaching one trillion dollars, 15 percent of the Gross National Product, cost containment is a major issue (Shortell, Gillies, & Devers, 1995). As of July of this year, 56 million people have joined managed care plans (Bennett Clark, 1996), and another 50 million will have joined by 2000 (Spragins, 1996).
TYPES OF HEALTH INSURANCE PLANS
At least 1,000 health insurance plans exist but they fall into certain categories (Whigham-Desir, 1996). The traditional plan has been the indemnity or fee-for-service plan. Patients visit any doctor at any time and pay directly for their treatment. They can be reimbursed later, usually for 80 percent of the cost (Whigham-Desir, 1996). These plans are the least restrictive, but the most expensive.
Four types of managed care plans exist. They are the health maintenance organization...