Performance Management Project

Solution Preview

Please see response attached.

RESPONSE:

3. Government regulations and accreditation organizations' influence

Let's explore some of the main regulations and accreditation by state and federal government for managed care. In fact, concerns about the effect of managed care techniques on the quality of medical care have been raised in many quarters. Physicians have advocated the reiteration of professional ethics or even the prohibition of market incentives in health care as solutions to the problem of cost-quality tradeoffs in managed care systems. However, there exist systems for the regulation of managed care that attempt to alleviate some of the potential problems posed by market-based competition.

A. State Regulations of Managed care (from http://www.annals.org/cgi/content/full/124/4/442).

- Management of care has inherent ethical problems, because incentives to provide low-cost care may be created without sufficient concern for patient welfare [28].

o For example, physicians can be responsible for much of the risk that actual medical expenses will exceed expected expenses for a panel of patients. It follows that economic gains, or prevention of major losses, could be made at the expense of appropriate care. A physician at risk for all ambulatory care could become too parsimonious as reserves dwindle because of unexpectedly sick patients. Some have suggested the appropriate ethical response to such pressures, but many states have also promulgated regulations to protect quality of care.

OBTAIN SPECIFIC LICENSES

? Regulation of managed care organizations by state governments is generally intended to protect patients by providing them with information and by ensuring the fiscal integrity of the organizations. Most states have long required traditional managed care organizations to obtain specific licenses.

o For example, the licensing authority, often the insurance commissioner, can regulate in all areas not preempted by federal law. States vary considerably in their regulatory approach, however.

o The Maryland provisions [29] are an example of an approach that encourages managed care organizations to provide high-quality care. Maryland requires managed care organizations to have regular hours; to provide for 24-hour access to a physician; to ensure that each member seen for a medical problem is evaluated under the direction of a physician; and to give each member an opportunity to select a primary care physician. Maryland also insists that managed care organizations provide appropriate preventive services and periodic health education.

 Maryland law also mandates that each managed care organization 1) have a written plan about its implementation of these standards of quality of care and 2) review statistics on the health care needs of its patients. Each organization must have an internal, professional peer review system that in many ways is modeled on peer review in hospitals. The systematic collection of ...