Overview and Summary: Managed Care

Key Words: Managed Care Programs

Before 1985 few persons had heard of "health care reform," "PPO" (Preferred Provider Organization), "PPS" (Prospective Payment System), "critical pathways," "capitation," and "managed competition." Now, in 1996, we are struggling to understand these and many other terms included in the vocabulary of health care reform. New terms emerge virtually on a month-to-month basis. It is a struggle, too, to understand the implications such fluidity in the health care system holds for each of us on a professional and personal level. Is the social goal of health for all compatible with viewing health care as a commodity? Can the enormous growth in health care costs be curtailed without reducing optimal health care to less than average care? Will "downsizing" to lower personnel costs result in loss of essential, although perhaps less visible staff, and registered nurses unable to find jobs? Can home health care quality be assessed and protected as demand for such care increases? What is the appropriate role for nurses to take in the debate on the national, state, local, and personal levels? Can the essence of a caring nurse-patient relationship be preserved in the case management role? Answers to these questions are proposed in the seven articles that comprise this issue. Authors familiar with the struggle who are actively seeking answers present their best "read" on the situation from their unique vantage points.

The first of the articles, written by Huntington, is the cornerstone for this issue. Not only is it a cogent primer of managed care terms, this article also is a comprehensive discussion of the complex managed care scene today. An especially useful aspect of this article is the fact that Huntington provides "links" to several important resources of additional information. Being able to click on a link and obtain the resource while reading the article is the real power of an online journal. Each of the articles that follows the first is a further exploration of aspects of the groundwork laid by Huntington. In addition, a common theme that runs through the articles is concern for providing high quality health care while responding efficiently to the rapidly changing demands of the health care market.

Both an Anonymous Physician and La Tourette worry that health care will deteriorate in the attempt to keep down costs. The physician's article conveys with clear examples the managed care quagmire in which he and other physicians find themselves. Also presenting an individual's perspective, La Tourette describes how he and other legislators are attempting to monitor the managed care industry. The next four articles deal with the question of health care quality too, but from the vantage point of the system level.

Bonner and Boyd, and Coulter write of the experience of nurse administrators in which business principles were applied successfully, in terms of quality, to circumscribed patient care systems. Responding to the dynamic tension created by the demands of cost and quality, Bonner and Boyd report the restructuring they did with their home health teams, and Coulter reports the challenge of restructuring patient care in a hospital setting. Booth succinctly describes change in the federal orientation to managing Medicaid/Medicare quality from the traditional approach of imposing standards to one of focusing responsibility at the managed care provider and state level. In the fourth system-level article, by Barr, the challenges presented by the change in the UK from a traditional "services-led" health care system to a "needs-led" managed care system are discussed. He worries that unless power is balanced between the client and professionals with active involvement of the client in the care process, managed care will remain a new form of a services-led system. Also included is a glossary of terms commonly used when discussing managed care. In the articles, links are provided to some of these terms to allow a reader a quick review. Not all the terms in the glossary are used in the articles, hence a reader may wish to look at the glossary apart from the links. More terms are also available at: www.uhc.com/resource/glossary.html while acronyms can be found at www.uhc.com/resource/acronyms.html

As a group, the articles posted in this Managed Care issue present a comprehensive picture of the current managed care environment. Readers will take away a deepened and broadened understanding of the inherent complexities. And because everyone reading the articles is affected to some degree by these complexities, the stands taken by the authors surely will provoke a response. We invite you to express your response in the form of either an article or a Letter to the Editor. By engaging in either form of response you will be taking advantage of another unique aspect of an online journal; the ability to participate in a timely way in the debate of a current nursing issue.

© 1997 Online Journal of Issues in Nursing
Published January 6, 1997

Citation: Budd, K., (Jan. 6, 1997) "Managed Care"Online Journal of Issues in Nursing Vol. 2, No. 1 Overview.