Managed care
Instructions
Discuss managed care, the initiatives implemented by private insurers to transform healthcare, and the various roles nurses play to improve quality patient outcomes tied to healthcare reimbursement. What are some strategies nurses can use to advocate for healthcare consumers and reduce the increasing cost of healthcare?
SAMPLE STUDENT ANSWER
Managed Care
Managed Care Definition
Managed care refers to a dual health provision system that focuses on the reduction of costs and ensuring high quality of health care (Archibald et al., 2018). It meant to harmonize costs, quality, and operation of health care provision. It aims to put a check on the cost of healthcare by establishing a network of providers, implementation of preventive care and utilization review and ensuring adequacy in primary care providers (PCP) and prescription drug tiers (Archibald et al., 2018, Kongstvedt, 2019).
It targets the skyrocketing cost of healthcare that is getting out of reach of most Americans due to various economic factors like unemployment. It is healthcare that is contracted to manage and execute both private and government health plans like Medicaid (Archibald et al., 2018).
Initiatives Implemented by Private Insurers to Transform Healthcare
Health insurance is a safety net that covers treatment costs when someone gets an unexpected sickness or injury. Since private insurers cover the biggest percentage of Americans providing cover to over 170 million individuals, have a big role in transforming health care (Ansell, 2021, Kongstvedt, 2019). Private insurance providers are now implementing strategies that reduce costs like preventive care and elimination of unnecessary costs (Archibald et al., 2018). Insurers are also moving towards systems that focus on patients like pay for performance in place of pay for service systems to cut costs (Archibald et al., 2018).
To deal with the provision of healthcare for complex reasons, private insurers are strategizing to use private clinics to have health hubs that improve healthcare access (Archibald et al., 2018). Increased awareness and penetrating are being done with a target of having all eligible people under insurance cover. There is also strategies to increase access to healthcare and convenience that use technology the Doctor on Demand programs that reduces waiting times by ensuring 24-hour access to PCPs (Archibald et al., 2018).
Roles of Nurses in Improve Quality Patient Outcomes Tied to Healthcare Reimbursement
Nurses have a major role to play in cost saving in healthcare by first preventing the application of unnecessary procedures, medication, and treatment (Salmond & Echevarria, 2017). This will have an effect of minimizing the hospital length of stay, readmission, and treatment durations. This can be achieved through diligence in reporting and documentation on patient progress to guide the physician in making clinical decisions like stopping a line of treatment once the patient has recovered (Salmond & Echevarria, 2017).
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Reduction and total prevention of hospital-acquired infections will be key in preventing extra treatment costs. Patient education and awareness on the management of the various health conditions will be key in preventive care and hence cost reductions (Salmond & Echevarria, 2017). Nurses can enhance the uptake and use technology like electronic record systems to eliminate needless and costly appointments and enhance efficiency in transfers (Salmond & Echevarria, 2017).
Strategies Nurses can Use to Advocate for Healthcare Consumers and Reduce the Increasing Cost of Healthcare
Nurses are required to provide the highest quality of health care at the most economical cost. This can be achieved by the managing of vital information like patients records in electronic forms that are easy to access and safe (Salmond & Echevarria, 2017). Nurses need to enhance the use of Telehealth to increase the number of patients connected to frontline workers (Salmond & Echevarria, 2017).
This will also reduce avoidable ER trips by patients who will baa be to get direct and immediate medical expertise and consultations from nurses. Nurses need to be involved in scheduling by management to reduce unnecessary cases of overtime that increase the cost of healthcare. Having adequate numbers of nurses in all the relevant fields will ensure timely interventions that will ultimately reduce the cost of healthcare (Salmond & Echevarria, 2017).
References
Ansell, D. A. (2021). The Poison Pill: Health Insurance in America. In The Death Gap (pp. 133-142). University of Chicago Press. https://doi.org/10.7208/9780226796857-012
Archibald, N. D., Kruse, A. M., & Somers, S. A. (2018). The emerging role of managed care in long-term services and supports. Public Policy & Aging Report, 28(2), 64-70. https://doi.org/10.1093/ppar/pry011
Kongstvedt, P. R. (2019). Health insurance and managed care: what they are and how they work. Jones & Bartlett Learning.
Salmond, S. W., & Echevarria, M. (2017). Healthcare transformation and changing roles for nursing. Orthopedic nursing, 36(1), 12. https://dx.doi.org/10.1097%2FNOR.0000000000000308