The concept of managed care, designed to control rising healthcare expenditures, is gaining traction globally, even while facing scrutiny in the United States. Interestingly, many foundational aspects of American managed care can be traced back to the British health system, despite notable differences between the two. Managed care, broadly defined as a system where health services are provided through a specific network of providers adhering to care approaches established via case management, has been present in the U.S. for a century. However, it only started achieving nationwide prominence in the mid-1970s.
What exactly constitutes managed care in the American context? It’s crucial to understand the different types of Managed Care Organizations (MCOs). While all Health Maintenance Organizations (HMOs) fall under the umbrella of MCOs, not every MCO is an HMO. The landscape further includes Preferred Provider Organizations (PPOs) and Point of Service (POS) plans, offering varied structures and access options.
Currently, a significant majority of individuals in the United States with health insurance are enrolled in managed care programs. Approximately three-quarters of insured Americans are within these plans, translating to over 160 million people. This substantial figure highlights the dominant role of managed care in the U.S. healthcare system.
However, the rise of managed care has not been without debate. A persistent discussion revolves around the comparative quality of care offered by MCOs versus traditional fee-for-service models. Studies attempting to settle this question have yielded inconclusive results, leaving the debate ongoing. Another contentious point within managed care is the inclusion of “gag clauses” in contracts between MCOs and healthcare providers. These clauses raise ethical concerns as they can restrict providers from fully disclosing information to patients, such as alternative treatment options or the specifics of provider compensation.
Since the U.S. healthcare reform efforts in 1994 did not achieve their intended goals, the market has increasingly become the driving force in cost reduction within the healthcare sector. Consequently, healthcare plans and providers are operating more like traditional businesses, where financial performance is paramount for survival. In a market driven by cost-conscious purchasers of healthcare, it’s important to remember that the quality and extent of care a society receives are generally reflective of the resources it is willing to allocate.
