Corresponding to my previous blog post, here I would like to explain why managed care health plans is recommended. First, lets see what people define "managed care".
" Managed care combines financing and delivery of health care in a single entity with the aim of
improving quality of care while controlling costs."
Bashir mamdani, Meenal Mamdani ( Managed care in the USA: history and structure)
A reminder here, the problems within health insurance system that I have mentioned in my previous post. First, non-insureds can't afford high expenses on health care. Second,quality of care in public health centers is impaired due to lack of competition or its status as non-profit clinic. From the definition above, we know that managed care aims to reduce the costs of healthcare and to ensure continuing quality of care. Thus, by implementing managed care, it is hoped that the problems would be solved. " Kill two birds with one stone" so goes this adage, seriusly, is it that easy?
Lets have a look how managed care works. Basically, the concept applied in managed care is to modify doctors' (or other professionals initiating care) actions in giving healthcare. This is to eliminate inappropriate treatments and to ensure a cost-effective healthcare practise provided. Below are the examples of measures which can be carried out to support managed care.
1) Developing networks and seeking preferred providers. Standards in selcting providers are established.
2) Financial incentives to encourage health providers to pratice more efficiently.
3) Establishing clear guildlines to help in making clinical decision.
4) An emphasis on preventive medicine
5) Using utilization review and quality improvement programmes.
2) Financial incentives to encourage health providers to pratice more efficiently.
3) Establishing clear guildlines to help in making clinical decision.
4) An emphasis on preventive medicine
5) Using utilization review and quality improvement programmes.
I believe that the above measures are not hard to be understood, except for the last one. What is utilization review? It is actually a retrospective review where treatments or services given that are recorder in medical files, are re-evaluated in comparison with treatment guidelines. Usually, this utilization review is used by the insurance company to determine clinical guidelines for a given condition.
So much for the ideal ways of how managed care works. The reality is that there is still some problems existed within this system. For instance, in Indonesia, Askes is one comprehensive social insurance scheme which is conducted based on managed care system. This programme is compulsory for civil servants (PNS, PTT, etc.) either still working or retired , retired military and police officers, veterans, and national patriots and their families to take part by making payment or premium and get a Kartu Askes.
So much for the ideal ways of how managed care works. The reality is that there is still some problems existed within this system. For instance, in Indonesia, Askes is one comprehensive social insurance scheme which is conducted based on managed care system. This programme is compulsory for civil servants (PNS, PTT, etc.) either still working or retired , retired military and police officers, veterans, and national patriots and their families to take part by making payment or premium and get a Kartu Askes.
Generally, managed care has some disadvantages due to the limited capacities:-
1) patient's access to care and their freedom
2) provider's ability to decide which diagnostic test and treatment to be ordered.
The patients who pay premium to be covered by Askes will go the healthcare centers insured by Askes. Sometimes, the health facility or health services doesn't meet the patients' expectation. For instance, the bed in hospital is not enough, doctor always come late and so on. Those patients who can afford, may choose to go private healthcare centers. Indirectly, this mean Askes programme has failed. Besides, patients found out that the drugs given are not paid by Askes sometimes. Why this is so? That is probably because some doctors has some kind of cooperations with private pharmaceutical company who agree to accept extra profits- the incentives. Again, the patients become dissapointed over the insurance programme.
In the lecture, Pak Gatot Subroto from PT Askes Jogja has said that Askes programme need support from the community, only if Askes make more than 50% of the hospital income, Askes could make some changes in those healthcare center. I think that it is more efforts should be implemented to cope with the internal problems within the hospital itself first. If patients found those hospitals or puskesmas provide a good quality of health care at minimum cost, they wouldn't have hesitated to get themselves insured by Askes.
References:
1) Lecture note by Pak Gatot Subroto :Managed care
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