Quality Assurance and Prevention in Managed Care

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1. Managed care philosophy and initiatives directed at prevention and health maintenance

What is managed health care? It's a system that controls the financing and delivery of health services to members who are enrolled in a specific type of healthcare plan. The goals of managed health care are to ensure that (a) providers deliver high-quality care in an environment that manages or controls costs, (b) the care delivered is medically necessary and appropriate for the patient's condition., (c) care is rendered by the most appropriate provider., and (d) care is rendered in the most appropriate, least-restrictive setting (Spivey, 1997, http://research.unc.edu/endeavors/win97/dial.html)..

The three major types of managed care plans are as follows, with each of these systems have distinctive features or characteristics (see extra information at the end of this response).

? Health Maintenance Organizations (HMO)
? Preferred Provider Organizations (PPO)
? Point-of-Service (POS) plans (Spivey, 1997, http://research.unc.edu/endeavors/win97/dial.html).

Managed care philosophy and initiatives directed at prevention and health maintenance within the managed health care, such as in a HMO is this:

"The hmo was designed to emphasize maintaining health rather than performing the expensive, acute interventions that generally characterize health care. The theory is that an hmo is paid a certain amount of money per patient per month to take responsibility for keeping the person healthy, so the organization has financial incentives to screen for disease and prevent costly illnesses or injuries. For example, if a patient has the potential for cardiovascular problems because of his genetic makeup or health history, we'll reduce costs if we give him nutrition and exercise counseling and risk-factor screening and treatment. It's less expensive to pay for one hour of nutrition counseling than to pay for the coronary artery bypass surgery that might ensue if the individual doesn't change his lifestyle. Managed care takes a macroview of the world in which we devote our attention and money to prevention; instead of doing one heart transplant, maybe we have the money to do 2,000 hypertension screening exams" (Spivey, 1997, http://research.unc.edu/endeavors/win97/dial.html).
However, Spivey (1997) found the HMOs are reluctant to spend money on prevention for a patient with the hope of a payoff coming in ten years, when in fact that patient may not be a member in even one year. She found that the HMOS that were most interested in prevention and improving community health were in a market where HMOs had been in the area for a long time and most people belonged to one. She concluded that these "organizations are more likely to spend money for prevention because a healthier community overall reduces expenses for the entire market" (Spivey, 1997, http://research.unc.edu/endeavors/win97/dial.html).

2. The nature of the problem of vaccinations and access to vaccines relative to prevention and health maintenance.

Membership in a health maintenance organization (HMO) is related to delivery of preventive clinical services such as vaccines to patients. Availability involves a patient's access to medical care, and if they lack the necessary resources, they are at a disadvantage and cannot receive the vaccine. Population who have been identified as disadvantaged are the poor, black Americans, the less educated and the elderly (Dawson, 2005). For example, Dawson (2005) found that there are appreciable disparities in receipt of preventive care by education among nonelderly insured persons. Differences in disparities between HMO members and non-HMO members reached statistical significance for influenza vaccination and showed a trend for mental health visits (P = .06). Moreover, HMO members with less than 12 years of education received services at levels comparable to non-HMO members with more education (http://www.sciencedirect.com/science?_ob=ArticleURL&_udi=B6TD4-4F7VNF1-5&_user=10&_rdoc=1&_fmt=&_orig=search&_sort=d&view=c&_acct=C000050221&_version=1&_urlVersion=0&_userid=10&md5=ec1a0a5afd77a8f2da6016de4e928bd2).

As well, the 'prevention problem' is a perceived injustice in the distribution of benefits and harms arising from population-based preventive vaccination policies. (Dawson, 2006, http://www.sciencedirect.com/science?_ob=ArticleURL&_udi=B6TD4-4F7VNF1-5&_user=10&_rdoc=1&_fmt=&_orig=search&_sort=d&view=c&_acct=C000050221&_version=1&_urlVersion=0&_userid=10&md5=ec1a0a5afd77a8f2da6016de4e928bd2). There are many anti-vaccinantion people. In factr, school vaccination laws, in particular, have been strenuously challenged by parents and other "anti-vaccinationists" ...