Managed care organization liabilities

While certain efficiencies and cost savings have been achieved, Managed Care Organizations (MCOs) have risk exposures never before considered. MCOs provide a number of services for their clients. Specifically, they are involved in credentialing, network development, utilization review, and the hiring and firing of physicians and other allied medical professionals subject to rather complex and detailed contractual arrangements. The insurance industry has responded to the increase in claim exposure associated with the aforementioned activities by providing any number of insurance products. Depending on the insurance provider, a number of different coverages are available. The final decision as to which coverage to purchase will be governed by the risks associated with a particular MCO, contractual protections, available cash flow, protections under federal and state laws. The point of this article is to apprise MCOs of the claims now starting to develop against MCOs as well as alternative insurance products that can be purchased in order to protect both the firm's assets as well as those of individual directors and officers.     

Managed care and HIV

In order to control costs, a transition from fee-for-service plans to managed care for people with HIV infections and AIDS is developing in the United States. The question arises whether a cost-conscious, competitive environment can deliver quality care to people with a disease that is complex and expensive to treat. Several options can be used to keep managed care from removing incentives for treating too many HIV and AIDS patients. Approaches include increasing capitation fees for patients who require more resources, and utilizing a carve-out approach from the State-managed Medicaid plans to separate HIV from the mainstream plans. However, rate determination under either option is problematic and may entail analyzing the cost of care under the fee-for-service system as a benchmark, including cost variations at various stages of HIV disease. This analysis also includes developing accurate adjustments for changes in treatment and assessing the quality of care that is received. Quality of care can be assessed through an analysis of outcomes, processes, and structures of care.     

Managed care. Dealing with the dual eligible population

This is the first of a two-part series reviewing the genesis of managed care programs for persons dually eligible for Medicare and Medicaid. Part two will profile several state programs, exploring their impact on long term care.     

Managed care and ethical conflicts

Managed care systems achieve efficiencies by rationing the resources used to deliver care. This rationing has led to widespread perceptions of patient abuse and neglect in the form of restricted access to care, denial of choice, and overall reduction in the quality of care delivered. Conflicts of interest and fundamental ethical principles are perceived as often compromised in the managed care environment. We argue that ethical issues are inherent in managed care and cannot be avoided. Recently, federal and state governments have passed legislation and regulations to deal with the issue.