Managed Care: A Bitter Sweet Perspective.
Rakesh Mittal, MD,PhD
President
HCA FL Northside Hospital medical staff
The American managed care system, while designed to control costs and improve healthcare efficiency, has faced criticism and has several pitfalls that can impact actual patient care. Here are some key pitfalls and their effects on patient care:
1. Restrictive Networks and Limited Access: Managed care often involves networks of healthcare providers with whom patients can seek care. While this can help control costs, it can also limit patients' choices and access to specialized or preferred providers. Patients may face challenges finding providers who meet their specific needs or have a trusted relationship with them, potentially leading to delayed or suboptimal care.
2. Prior Authorization Requirements: Managed care systems commonly require prior authorization for certain procedures, tests, medications, or specialist consultations. These requirements can result in administrative burdens for physicians and delays in patients receiving necessary care. The process of obtaining authorization may involve time-consuming paperwork and potential denials, creating barriers to timely treatment.
3. Cost-Sharing and Financial Barriers: Managed care often involves cost-sharing mechanisms such as copayments, deductibles, and coinsurance. While these mechanisms aim to encourage cost-conscious healthcare utilization, they can create financial barriers for patients. High out-of-pocket costs may discourage individuals from seeking necessary care, leading to delayed or inadequate treatment and potentially worse health outcomes. the affordable Care act even though was good to insure patients with multiple medical problems with no exclusions of health issues became very costly with high deductibles. many of those patients don't seek care because of extremely high deductibles and so choose not to go to a doctor for early intervention because they just cannot afford the copay or deductible. it's a catch-22: To have insurance but can't afford to use it. There should be a better way
4. Provider Payment Mechanisms: Managed care systems typically use payment models that incentivize cost containment. This can lead to financial pressures on healthcare providers, with potential consequences for patient care. Providers may face incentives to deliver care quickly or limit services to control costs, which could compromise the thoroughness or quality of care delivered. high risk contracting with providers face similar dilemma where the provider is paying for most of the care and therefore inadvertently, unintentionally justifies withholding care. most patients don't even understand that kind of arrangement.
5. Administrative Burdens: Managed care systems often involve complex administrative processes, including claims management, documentation requirements, and coordination of care among various providers. Physicians may spend significant time on administrative tasks, detracting from the time available for direct patient care. These administrative burdens can lead to physician burnout and potentially impact the quality and continuity of care.
6. Fragmentation of Care: Managed care systems may involve multiple layers of administrative oversight, leading to fragmented care delivery. Fragmentation can hinder care coordination, communication, and continuity across different healthcare settings or providers. This can negatively impact patient outcomes, especially for individuals with complex or chronic conditions who require comprehensive and coordinated care.
7. Focus on Short-Term Cost Savings: Managed care systems often emphasize cost containment in the short term, which can sometimes overshadow long-term healthcare quality and outcomes. Measures aimed at immediate cost reductions, such as limiting access to certain medications or procedures, may not consider the potential long-term benefits or cost savings associated with preventive or early interventions.
8. Potential for Underinvestment in Prevention and Primary Care: The cost-focused nature of managed care systems may inadvertently lead to underinvestment in preventive care and primary care services. These services play a crucial role in promoting early detection, disease management, and overall health maintenance. Insufficient emphasis on prevention and primary care can result in a higher burden of illness and increased healthcare costs in the long run.
It's important to note that not all managed care systems are alike, and some variations may address or mitigate these pitfalls more effectively. However, the potential impact on patient care highlights the need for ongoing evaluation and refinement of managed care models to ensure they strike the right balance between cost control and patient-centered, high-quality care.
The bottom line is that with increasing technology, Superior medications, and ever changing medical knowledge there's absolutely no cheap way of treating patients no matter how we justify it. Quality Care almost always comes with a Price that unfortunately, most people don't have or can pay for, in higher insurance premiums.
On the other hand if we would just pay attention to prevention, frequent follow-ups for early detection, low to zero co-pays to see physicians would mitigate long-term costs and medical expenses for everyone. Most importantly governments should promote a healthy lifestyle rather than catering to lobbyist and vested interest corporations that promote or sell the exact opposite.
