Managed
care is of great interest and concern for older adults and caregivers.
With increased age older adults are at
higher risk for chronic disease. Therefore, in need of health care and
perhaps on limited incomes, they use Medicare or seek the lowest premium
for medical care. Managed care usually offers the lowest cost for the most
benefits and several managed care companies have recently become the brokers
for Medicare services. Additionally, more older adults are enrolling outright
in managed care companies. Hence, it is helpful for older adults and persons
working with older adults to better understand what managed care offers
and its limitations.
Many
web sites and other documents provide detailed descriptions of managed
care. This section will focus on the
older adult perspective, describe it very generally, cite potential problems,
and finally list provocative questions for those considering managed care.
Managed
care is a system that combines in one package the services of health care
providers with financing of an insurance company. Emphasis
is on the prevention of medication, appropriate care and coordination of
care. One goal is to decrease the costs for all to benefit through the
decreased selection of doctors and other professionals and careful screening
and delivery of high tech procedures and special services.
Ten
percent of Medicare beneficiaries use managed care instead of Medicare.
Medicare Health Maintenance Organizations
(HMOs) are an option. Medical managed plans vary by: where the services
are provided; how much care is provided; how government pays them; for
profit or nonprofit organizations are used; the degree of choice of providers
and the types of services rendered.
Some
Problems that have been Identified in some Managed Care Programs may have
Ethical Implications and May Include:
Refusal
to pay for emergency room or urgent care
Deceptive
enrollment of people without their permission
Illegal
health screening as a prerequisite to membership
Refusal
to refer to specialists
Inadequate
diagnostic assessments
Failure
to inform HMO members of their appeal rights
Inadequate
government monitoring of the plans to document compliance with federal
law
Lack
of public access
Failure
to provide minimally mandated Medicare benefits for the seriously ill and
disabled, especially for nursing home and home health care
Lack
of choice in medical care providers
Encouraged
use of generic medications
Early
discharge from the hospital
Disincentives
for physicians to spend adequate time and testing on individual patients
The
following Questions may be Indicators of Quality in a Managed Care Program:
- 1. Is the plan accredited or has it applied
for accreditation? The National Committee for Quality Assurance accredits
plans and reports quarterly?
2. Does the plan publish a current list of providers available to prospective members?
3. Does the plan include the doctor with whom you have a well-established relationship?
4. Does the plan regularly evaluate its quality of care and take initiatives for improvement?
5. Does the plan disclose how it and its doctors are compensated?
6. Does the plan conduct periodic member satisfaction surveys, and can I obtain results before joining?
7. Does the plan operate urgent care centers for after-hours treatment that are conveniently located for me?
8. Does the plan require continuing education for its health professionals that includes training in the special needs of older people?
9. Does the plan have a telephone line for prompt evaluation by a health care professional of the need for urgent care?
10. Does the plan have member advisory council for consumer input?
11. Is there an appeal process and how does it work?
Center on Aging Studies | University Outreach and Extension |
University of Missouri HES Extension | UMKC
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email Lois Fitzpatrick