Types of Managed Care Organizations according to Peter Kongstvedt

Its is almost a certainty that new approaches to managing cost quality, and access will be developed, some will fail, while others will succeed and lead to still more changes. Health care cost have risen at variable rates, and the shocking increases experienced in the early 1990s slowed in the mid-1990s but have begun to appear again at the turn of the 21st century (Kongstvedt, 2003).

Managed care has been effective in holding down the rate of rise, but many of the fundamental reasons for increased health care cost remain today which include rapidly developing medical technology, drug therapy advances and rising prescription drug prices, shifting demographics, especially the aging of the population, high expectations for a long and healthy life, greater control of health care by consumers and associated demands upon the health care system, the litigiousness of our society which leads physicians to practice defensive medicine, high administrative cost related to the care that is delivered, inefficient or poor quality care rendered by some providers, high cost of compliance with government mandates, decreased levels of public dollars to pay for entitlement program health care, and lastly, cost shifting by providers to pay for health care rendered to patients who either cannot pay or are covered by systems that do not pay the full cost of care (Kongstvedt, 2003).

While the term managed care can be defined in many ways and is constantly evolving to meet the demands of the health care market, the differentiating feature of managed care relative to FSS is the use of provider networks (McCarthy, 2004). Defining the different types of managed care organizations (MCOs) is an ever-evolving challenge. Ten to fifteen years ago, it was relatively easy to distinguish among different types of MCOs (Kongstvedt, 2003). According to Kongstvedt, health maintenance organizations (HMOs), preferred provider organizations (PPOs), and the more recent point-of service (POS) health plans were the distinct types of organizations and were identified as such.

MCOs are the predominant vehicles for the provision and payment of health care benefits, at least for the private sector, and more often, seemingly pure MCO will be a subsidiary of a larger health plan or insurance company that offers the other types of MCOs to the same market (Kongstvedt, 2003). The perceived success of HMOs and other types of managed care organizations in controlling the utilization and cost of health services prompted the development of managed care overlays that could be combined with the traditional indemnity insurance, service plan insurance, or indemnity like self insurance (Kongstvedt, 2007). These managed care overlays are intended to provide cost control for insured plans while retaining the individual’s freedom of choice of provider and coverage for out-of-plan services.

The types of management overlays include general utilization management, specialty utilization management, disease management, catastrophic or large case management, and worker’s compensation utilization management. Typically, participating providers in PPOs agree to abide by utilization management and other procedures implemented by the PPO and agree to accept the PPO’s reimbursement structure and payment levels, and in return, PPOs may limit the size of their participating provider panels and provide incentives for their covered individuals to use participating providers instead of other providers (Kongstvedt, 2007). In contrast to traditional HMO coverage, individuals with PPO coverage are permitted to use non-PPO providers, although higher levels of coinsurance or deductible routinely apply to services provided by these non-participating providers.

POS plans essentially combine an HMO or HMO-like health plan with indemnity or service plan coverage for care received outside of the HMO. Once touted as yet another wave of the future, they grew in the mid 1990s only to decline in popularity as their hoped-for cost savings failed to materialize. There are two ways in which POS plans were organize, depending on the vehicle to provide the HMO or HMO-like services (Kongstvedt, 2007). These types of POS plans are hybrid of more traditional HMO and PPO models, though they are licensed as PPOs, and the characteristics of these types of plans are, first, primary physicians may be reimbursed through capitation payments (i. e.

A fixed payment per member per month) or other performance based reimbursement methods, second, there may be an amount withheld from physician compensation that is paid contingent upon achievement of utilization or cost targets but some states restrict the ability of managed care organization to establish withholds, and they become less common over time, third, the primary care physician acts as a gatekeeper for referral and institutional medical services, and lastly, the member retains some coverage for services rendered that either are not authorized by the primary care physician or are delivered by non-participating providers, and such coverage is typically significantly lower than coverage for authorized services delivered by participating providers – e. g. 100% compared to 60% (Kongstvedt, 2007). Managed care is on a variety with plan types giving a collection of feature that differ in their capacity in balancing the access to cost, care, quality control, flexibility, and benefit design, and the health care delivery systems’ rise and evolution (Kongstvedt, 2007).

As consolidation in the market place continues, it will blur the lines further, and although there is no one single definition of the term managed care that has endured in the past or will survive in the future, the basic tenets of managed health care will continue to evolve in pace with market demands and requirements (Kongstvedt, 2007).. References Kongstvedt, P. R. (2007). Essentials of Managed Health Care. New York: Managed Care Plans. Kongstvedt, P. R. (2003). Managed Care: What is it and How it Works. New York: Managed Care Plans. McCarthy, R. L. , & Schafermeyer, K. W. (2004). Introduction to Health Care Delivery. New York: Jones & Barlett Publishers.

Calculate the price
Make an order in advance and get the best price
Pages (550 words)
*Price with a welcome 15% discount applied.
Pro tip: If you want to save more money and pay the lowest price, you need to set a more extended deadline.
We know how difficult it is to be a student these days. That's why our prices are one of the most affordable on the market, and there are no hidden fees.

Instead, we offer bonuses, discounts, and free services to make your experience outstanding.
How it works
Receive a 100% original paper that will pass Turnitin from a top essay writing service
step 1
Upload your instructions
Fill out the order form and provide paper details. You can even attach screenshots or add additional instructions later. If something is not clear or missing, the writer will contact you for clarification.
Pro service tips
How to get the most out of your experience with MyStudyWriters
One writer throughout the entire course
If you like the writer, you can hire them again. Just copy & paste their ID on the order form ("Preferred Writer's ID" field). This way, your vocabulary will be uniform, and the writer will be aware of your needs.
The same paper from different writers
You can order essay or any other work from two different writers to choose the best one or give another version to a friend. This can be done through the add-on "Same paper from another writer."
Copy of sources used by the writer
Our college essay writers work with ScienceDirect and other databases. They can send you articles or materials used in PDF or through screenshots. Just tick the "Copy of sources" field on the order form.
See why 20k+ students have chosen us as their sole writing assistance provider
Check out the latest reviews and opinions submitted by real customers worldwide and make an informed decision.
Business and administrative studies
excellent work
Customer 452773, March 9th, 2023
Business and administrative studies
excellent job! got an A, thank you
Customer 452773, May 24th, 2023
Criminal Justice
This has been the greatest help while I am recovering from an illness. Thank your team so much.
Customer 452671, May 2nd, 2021
Customer 452591, March 18th, 2021
Leadership Studies
awesome work as always
Customer 452773, August 19th, 2023
Social Work and Human Services
Great work I would love to continue working with this writer thought out the 11 week course.
Customer 452667, May 30th, 2021
Love this writer!!! Great work
Customer 452597, April 5th, 2021
Criminal Justice
The paper was not accused of plagiarism and was written very well. I will let you know the grade once it is graded. Thank you
Customer 452671, April 26th, 2021
Human Resources Management (HRM)
Customer 452773, July 11th, 2023
Thank youuuu
Customer 452729, May 30th, 2021
Thank you for your hard work and help.
Customer 452773, February 13th, 2023
Thank you!
Customer 452545, February 6th, 2021
Customer reviews in total
Current satisfaction rate
3 pages
Average paper length
Customers referred by a friend
15% OFF your first order
Use a coupon FIRST15 and enjoy expert help with any task at the most affordable price.
Claim my 15% OFF Order in Chat

Sometimes it is hard to do all the work on your own

Let us help you get a good grade on your paper. Get professional help and free up your time for more important courses. Let us handle your;

  • Dissertations and Thesis
  • Essays
  • All Assignments

  • Research papers
  • Terms Papers
  • Online Classes
Live ChatWhatsApp