Research Paper on Managed Care

1. Introduction

In this research paper I will investigate in Managed Care development in the USA and its importance in relation to the overall Health Care reform.

In order to evaluate the influence of Managed Care, it is necessary to follow all stages of its development, starting with its emergence, estimate its consequences, key parameters, understand all advantages and disadvantages not only from the standpoint of the client companies, but also for counselors who are working in Managed Care Organizations.

Managed care as the separate notion emerged in the beginning of 1990s and had a great impact upon counseling and psychotherapy practices. The great problem at the very beginning was that there were almost no books for beginners and the new staff lacked professionalism. The main reason for establishing managed care was the need in cutting costs for medical treatment, and managed care succeeded in fulfilling this particular task, although the situation not appeared to be constant. Consequences for cost reductions were rather rough, as managed care organization reduced costs not by means of increasing efficiency of services provided, but by decreasing number of clients and decreasing funding of service providers. Managed care brought a lot of new rules and regulations that seemed like another language to counseling professionals, and even though they were knowledgeable in their spheres, they had to start learning again in order be able to co-exit with this new type of health care. There was a conflict between providing best care services at lower costs, as he fuller and the better range of care services, the higher are the prices.

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2. Reasons for Managed Care

Prices for medical services at the beginning of the 90s were constantly increasing. There were few reasons for that, which included: increases of inflation rates, increases of the costs for the mental health. Lack of professionals is definite spheres also made an impact upon this decrease. Some other reasons included: more services were used by the elder people and aging population, improved medical technologies needed more funding; a lot of money were spent on administrative and supportive staff.

At the same time federal government started the process of industrialization of health care system in USA. Creation of centralized and structures managed care was inevitable. Even though managed care organization emerged in the beginning of the twentieth century (Western Clinic in Tacoma, 1910, Farmers’ cooperative Health Plan in Oklahoma, 1929 and Kaiser Foundation Health Plans, 1937), the real necessity in them appeared just during last two decades. Starting with this very point, there were proposed three basic stages of behavioral managed care development. The first stage can be characterized by shifting of traditional health insurers (for example, of Blue Cross) to Health Managed Organizations. Their goal was increasing savings and revenues. So, now they focused more upon gaining profit and not providing qualified medical help. These goals were achieved by means of cutting access to particular services (providing only one program out of several that can be four ours by car away). The second stage was about focus upon large employers, making them the target market. Behavioral health was strongly encouraged to be separated from other medical services. Means were very different for achieving this- from publicity to personal persuasion. Large companies, in their turn, demanded cost control, discounts, and minimum complaints from the side of patients. The last stage was characterized with the consolidation of the managed care organizations, with the disappearance of traditional insurers from the market and drastic increase in number of licensed professionals who were willing to work, and subsequent decrease in their income.

The another researcher of this question- VanLeit- claimed that there were only two phases for managed care organizations formation. The first one is characterized by seeking for cost effectiveness and hostile relationships between managed care companies and providers, as well as by attempts to pay attention to quality and care effectiveness. The financial risk was shifted to health care providers, which leas even to more mistrust in their relations.

3. Consequences of managed care

The first and the most important consequence of managed care became lack of adequate health care. Results of the conducted research showed that people were not satisfied with the provided services, haven’t received in-time services or had problems regarding paying for services. The limited number of providers’ strategy that was originally used to save costs, resulted in bad treatment services, and showed no improvements. When the company that should have take care of people’s health, transfers to the mission of gaining more, then there is nothing to say about what kind of service they would provide. And even though such a switch was an obligatory measure stipulated by the lack of state funding, quality should also be pursued in any case. There was the change in the types of services offered. The psychotherapy and psychological testing became less profound and complicates by switching to more brief therapy, crisis intervention, medication and substance abuse treatment. The level of specialists also decreased from doctoral levels to common nurses, psychiatrists and bachelor-level specialists.

Simultaneously with all stated consequences, the amount of paper work increased as well as administrative expenses, as the number of administrative staff was greatly decreased, effectiveness of work in this sphere decreased greatly. Practicing doctors were wasting lot of time for administrative work and performed less of their direct job tasks. Another problem with paper work was for the client companies and providers connected with constantly changing rules, regulations and forms. Training opportunities were also very restricted, because of lack of financial resources. Students, who were willing to practice their skills, not payment for their ob was offered for the reason that they were not licensed yet. So, students had problems in acquiring enough clients during their practice. Training problems finally resulted in decreased ability to ensure training upon long-term basis mental health, and switching to short-term, as well as in additional stress for staff in viewing students as additional burden to their every-day responsibilities.

There were also legal and ethical contradictions that counselors faced connected with the provision of the best care services along with least expensive for the managed care organization (time-consuming). Confidentiality was also an issue to be considered, as managed care companies needed information that could violate clients’ privacy, which could not be guaranteed. So, in general terms, medical model of health care was interchanged by the business model with subsequent changes in core values and service quality.

4. Work conditions for providers in Managed Mental Health Care

Counseling process and discussed issues had always been the private matter of the client and the counselor. But with the emergence of managed care organizations, this could not be longer guaranteed. Prior to managed care, any outside influence was viewed as the intrusion to the private life and was not considered ethical. Any outside influence or attempts for evaluations were strictly forbidden. In managed care companies, specialists, when trying to evaluate the overall efficiency of the counseling process, were violating primary ethical standards of behavior.

Definite instructions and complex, and sometimes contradictory, requirements were developed for counselors to obey. They were dictated how to behave themselves during sessions as well as in the office.

Provider panels had the series of limitation for membership, including geographical limitations, difficulties in starting of the new practice in new place (is not referred to rare specializations), group panel membership, which had a lot advantages especially for newcomers and provided an ability to combine private and group practice.

Contracts were another big problem with managed care organizations for both providers and clients. If the client was not paying for services provided, the counselor still had to continue his sessions with the client.

When the contact was once signed, it was very difficult to change any of its issues. It was prohibited to discuss with the client any topics beyond indicated in the contract. It was allowed to do and to treat only what was written in the insurance and nothing more. If the patient needed any additional sessions or treatment course, it was the company’s prerogative to decide it, even if the treatment was not successfully finished. It usually took a lot of time for the decision-making process for companies’ to extend the treatment, and in some cases the disease already could took more serious form and needed far more time and investments.

Each therapist should also remember that the company could stop sessions any time without notifications. And therefore each new treatment session was like the last on.

Also strict diagnostic criteria were developed and if the client was not corresponding to any, he or she were refused to be treated or just offered to purchase the better insurance.

Client should have been informed that have the limited number of sessions, so that they didn’t feel themselves suddenly left alone. Client companies received all information about treatment sessions and the contract requirements were not considered closed, unless all information was delivered.

Each therapist should have developed the treatment plan and to follow it. The common treatment plan included a formulation of the problem occurred, description of the therapeutic intervention, and the desired result of the treatment. Effective treatment result depends not only upon the treatment effectiveness, but also upon the cooperation of managed care organization, the client company and their allowing therapist to work competently and provide in-time services.

As to the providers work conditions, I would like to summarize that all procedures and instructions appear to be directed to the discouragement both to work and to use counseling services, as the neither allow effective service delivery, not afford obtain the qualified assistance. Clients are obliged to face delays and providers are to wait long for payments and experience high administrative expenses.

5. Managed Care Evaluation

Evaluation of any services provided is the key task of management and the driving force for constant improvements. In case with managed care, the only thing that is needed to know the customer satisfaction is to ask clients about it upon constant basis. But the information is usually collected by managed care companies and data collected can be interpreted in any ways, depending what the company wants to emphasize. As data is not available to broad public, but only statistical outcomes, there is no evidence that results depict the true situation. No data follow-ups were also practiced. So, there were no improvement expected in the quality aspect for the simple reasons that managed care companies didn’t possess enough valid information about how reliably improve psychotherapy and counseling services; there is little evidence that data collected is relevant, as not all client companies equally share information and the results can be taken just from the small sample group and be subjective. And the last reason was about that there was no evidence that managed care companies would have been motivated with any factors beyond profit.

There could be several possible solutions, including setting external common standards for evaluation so that all criteria, sample size, etc. were common for every company and the information be publicly presented. Multiple sources for making up reports should be used, as well as examination of the frequency of medical services use after the counseling process was finished, idiographic assessment involvement, developing general basic quality standards for outcome assessment. Cost reduction can be proposed to be done without influence upon quality by means of subsequent psychotherapy that would result in providing less medical and surgical services.

6. Managed Care Improvement

Managed care companies in general are not willing to change their way to do business. And then the question arises upon whether the basic care that they provide is good or bad. In order to answer it objectively, it is necessary to understand to whom good or bad. For client companies (who take care of its employees), patients (who just want to be health and happy) and government (that has to protect rights of its citizens)- it is bad, for managed care companies, which are looking for cutting expenses and gaining more profit, it is good. And the task is to find the best solution, which would benefit both sides, as health care crisis is the stumbling block of ethical standards and human rights.

There are several suggestions to improve quality of managed care services delivery, which are primarily connected with establishment of democratic allocation procedures, fair grievance procedures and also practicing more respect for privacy and confidentiality. And there were developed nine directions that would improve activities of managed care organizations. The first one is about continuing transition from inpatient to outpatient services, as this step would reduce costs for providing mental health services, as there is little evidence that inpatient treatment is more effective then outpatient and costs for providing outpatient services are much less. The second hint refers simplifying managed care and medical bureaucracy- less administrative work- less expenses. The third advice concerns constant investments in the research. Even though such investments are long-term ones and will not be paid back immediately, they are essential driving part of contemporary managed care. The forth hint concerned removing control of health insurance from employers. The fifth advice is about having enough supportive staff at the managed care companies, so that each staff member was doing his or her particular job, there were no overlapping job responsibilities and no staff deficit. Traditional labor strategies are also firmly advised to be considered as well as offering managed care to the educational programs and giving students the opportunity to receive practical experience. Managed care professionals should be politically active and participate actively in lobbing laws and regulations about managed care. And finally counseling professionals should stay informed about all changed occurred not only in their organization, but also from outside (professional newspapers, journals, web-sites, etc.). It is very helpful to share own experiences, successes and problems with other specialists and to hear their opinions, acknowledging something new and constantly improving professional skills.

7. Conclusion

In the conclusion I would like to mention that managed care organizations played one the dominant roles in Health Care reform. Even though their operations are not always successfully managed and delivered, managed care serves as the driving force for constant health care improvement and pursues the main goal of the reform – decrease of health care costs.

Managed care was an absolutely new experience for both health providers and company clients and therefore it was not always smoothly going. Health providers were underpaid and were put into strict frames in delivering their services. Clients had to wait for sessions and may not receive the expected help, but in general managed care organization should primarily pursue the goals of effectively helping people with their problems and not thinking just about profit. Probably there should be more government funding, but still the question remains open.
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