Does 'managed care' need redefining?

As value-based reimbursement becomes the standard in the healthcare industry, managed care will become a more central component of patient care.

The working definition of managed care is a system of providing care that is designed to control costs through managed programs in which the physician accepts constraints on the amount charged for medical care and the patient is limited on his or her choice of physician, according to Merriam-Webster's medical dictionary. Managed care stretches from organizations such as Pasadena, Calif.-based Kaiser Permanente, which is classified as a managed care organization, but it also includes Medicaid plans that pay the clinicians' fee for service and "call it a day," according to an article in the American Journal of Managed Care.

Certain types of MCOs serve as both insurer and provider, which allows them to manage benefits as part of the managed care experience. These organizations can benefit from more clear outlines of the requirements of managed care, according to the article.

There are leadership elements as well as technical elements which can be addressed to better implement managed care. Managed care, including benefits management, must be based on insights from comparative effectiveness research and discourage the use of services known to be unsafe, ineffective, inferior to alternatives or non cost-effective, according to the article. Proper clinical managed care includes elements such as:

∙ Proactive management of conditions between visits

∙ Good information systems with clinical decision support

∙ Predictive analytics to identify patients most likely to benefit from intervention

∙ Use of patient registries

∙ Care teams that include a variety of clinicians

∙ Strategies to address the non-medical determinants of health

∙ Management of patient experience, informed by patient surveys

∙ An emphasis on shared decisionmaking

Properly managed care should also include the patient, especially for those with chronic conditions, the authors wrote. Health IT products to encourage patient engagement could help drive this involvement, including tools such as patient portals, apps, smartwatches, bio sensors and collaborative projects such as OpenNotes, according to the article.

"These and other methods for elevating patients' agency and decision making are increasingly demanded by patients, and they should be part of the managed care concept for the 21st century," the article read.

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