Custom «Managed Care » Essay Paper Sample

Managed Care

Managed care is a practice whereby patients are enrolled into a system that makes payments, on behalf of the patient to health care providers, with the aim of shifting the charges from the patient to the providers' sponsors (Noble & Brennan, 1999). Most patients that have been enrolled under such schemes have raised several complains about the services offered by under this scheme. Three of the major complains include; dissatisfaction with the quality of the health care services offered by some of the service providers, complexity in getting appointments with the specialists and denial of referrals to see specialists (Mechanic, 2004).

Just like any other area that deals with the well being of the citizens, health care is also regulated by some federal laws so as to ensure that patients get the right services without being oppressed. Some of the laws that have been enacted in health care include; Consolidated Omnibus Budget Reconsolidation Act (COBRA), Employee Retirement Income Security Act (ERISA) and Gag Clause Law among others (Noble & Brennan, 1999).

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Employee Retirement Income Security Act (ERISA) is a federal act that is concerned with setting minimum standards for most willingly health and pension plans established in private companies with the intention of protecting individuals registered under such plans (Rosenthal et al., 2002). Since its endorsement in 1974, several amendments have been made so as to expand the protection to beneficiaries and participants of health plan. One of the amendments is the Health Insurance Portability and Accountability Act (HIPAA). This adjustment provides new security for working Americans, together with their beneficiaries, who have existing poor medical records or are feared to suffer prejudice in health care coverage as a result of their conditions. Other amendments include; Consolidated Omnibus Budget Reconsolidation Act, Newborns' and Mothers' Health Protection Act, Women's Health and Cancer Rights Act and Mental Health Parity Act (Noble & Brennan, 1999).

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Consolidated Omnibus Budget Reconsolidation Act (COBRA) is an act that puts in adjustments to the Employee Retirement Income Security Act, Public Health Service Act and Internal Revenue Code so as to offer continuation of employees' health coverage (Noble & Brennan, 1999). The act provides employees, and their beneficiaries, who have lost their health benefits due to unemployment the right to continue enjoying health benefits offered by their group health plans (Noble & Brennan, 1999). Other circumstances, apart from unemployment, that may make an individual entitled to continue enjoying health care benefits include; involuntary or voluntary loss of job, decrease in the number of working hours and unavoidable transitions and events such as divorce and death. In most cases, eligible individuals are required to pay an insurance premium for the health coverage of equal to 102% of the total charges of the plan (Rosenthal et al., 2002).

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Gag Clause is on the other hand a law that forbids physicians and nurses from forthrightly talking about all possible treatment options, insured or uninsured, cheap or expensive, that would benefit the patient (Mechanic, 2004). Some of the information that practitioners are prohibited to share with their patients includes; discussing anticipated treatments before getting authorization, giving health plan members' phone numbers as well as discussing with them the operation oversight process. In other words, it is an information protection agreement that is signed between managed care organizations and the providers of health care services so as to restrict the amount of information that the provider can share with the plan beneficiaries. The purpose of this contract is to limit the conditions under which a care provider may express disapproval of certain treatment options (Mechanic, 2004). In addition to this, the clause also prohibits practitioners in Health Maintenance Organizations (HMOs) from giving patients details about consultants or other health care providers outside the plan.

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