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What Are the Pros and Cons of Managed Care?

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  • Written By: Malcolm Tatum
  • Edited By: Bronwyn Harris
  • Last Modified Date: 11 September 2016
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Managed care is a term that is used to describe an approach to healthcare involving a conscious effort to structure the process of obtaining medical care in a manner that helps to keep expenses as low as possible. Many of the health insurance plans today are designed with this idea of managed care in mind, often utilizing specific strategies to ensure that the procedures conducted are in the best interests of the patient and not performed simply to create massive medical bills. While the general concept of managed care is attractive, there are also some potential liabilities that should also be considered.

One of the advantages of managed care is that health insurance plans using this approach often negotiate lower rates for basic healthcare procedures with physicians, labs, and various types of healthcare facilities. What this means for the patient is the ability to obtain basic healthcare at a lower cost. This in turn makes it much easier to seek medical attention when it is needed, without being unduly concerned about the impact that doctor visit or stay in the hospital will have on the household budget.

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Another advantage of managed care is that many health insurance plans operate with the use of a wide range of physicians and specialists who are connected with the insurance provider’s network. In some situations, this can make it much easier to locate a particular type of physician when needed, often being able to choose from several different medical professionals when a specialized course of treatment is needed. For people who may be somewhat intimidated by having to find and qualify specialists for needed medical procedures, the fact that the managed care plan includes a roster of physicians who have already been qualified by the insurance provider can be extremely helpful.

While managed care programs do often provide a valuable service, it is important to note that there are some potentially adverse circumstances that may prevail. Choosing to use a physician who is not in the plan’s network may result in decreased benefits paid, or even total rejection of all claims. In addition, the fact that a particular physician is in a network does not mean he or she is automatically available. It may still be necessary to seek medical attention from another medical professional in order to obtain the highest level of benefits. Even then, some patients may find it necessary to wait a considerable amount of time before being able to schedule an appointment, especially if that available physician is carrying a larger patient load.

Obtaining services from a specialist is also sometimes more complicated with managed care. With many plans of this type, a referral to a specialist by a general practitioner may be necessary before the insurance provider will cover the costs of that visit. The same is true with procedures that must be done in a hospital or surgery setting. Simply put, the patient cannot bypass the general practitioner and choose to go directly to a specialist or arrange for a procedure and hope to have the cost covered by insurance.

It is important to note that the specifics of the health insurance plan will have a significant impact on what benefits are provided to the insured party, and what potential liabilities may be present. Since several different types of managed care plans are currently in existence, with some allowing patients greater discretion in the selection of physicians and control of their own health care needs, evaluating the specific plan and deciding if the benefits outweigh the liabilities is very important. Doing so can make the difference between being able to obtain quality care when needed and having to find ways outside the plan to subsidize healthcare needs that are desired but not considered necessary or covered under the terms of a plan.

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Animandel
Post 2

Managed healthcare receives more than its share of criticism. The system is far from perfect, but without managed health care, many more people would be unable to afford health insurance. We complain about the price of healthcare in the United States now. Without managed healthcare, I don't want to think how much more health procedures would cost.

Also, for every horror story associated with managed healthcare there are so many more cases in which everything has worked, if not perfectly, well enough that patients voiced no complaints.

One of the main complaints I hear is that patients are often unable to use the doctors they want to use, and I agree this is a problem, but remember you

can choose your doctors, but you may have to pay more. The choice is still there. If you want to see what healthcare might be like without this system, read more about the history of managed care and how and why it began.
pollick
Post 1

After what my wife went through in an ER one time, I always tell people to make sure they know if a particular doctor is in their network or not. The hospital or the doctor may not provide that information before treatment starts. We weren't thinking about health care plans or preferred physicians at the time. We just wanted her to be seen and treated by a doctor right away.

It was only afterwards when the bills came in that we found out the doctor on duty in the ER that day wasn't on our plan's list. He could charge his regular physician's fees, several hundred dollars, and none of it was covered by insurance. It's one thing for a managed care plan to recommend a specialist, but another thing to end up in an emergency room and not know which doctors are covered and which are not.

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