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The term managed care or managed healthcare is used in the
United States The United States of America (U.S.A. or USA), commonly known as the United States (U.S. or US) or America, is a country Continental United States, primarily located in North America. It consists of 50 U.S. state, states, a Washington, D.C., ...
to describe a group of activities intended to reduce the cost of providing
health care Health care or healthcare is the improvement of health via the prevention, diagnosis, treatment, amelioration or cure of disease, illness, injury, and other physical and mental impairments in people. Health care is delivered by health pr ...
and providing American health insurance while improving the quality of that care ("managed care techniques"). It has become the predominant system of delivering and receiving American health care since its implementation in the early 1980s, and has been largely unaffected by the
Affordable Care Act The Affordable Care Act (ACA), formally known as the Patient Protection and Affordable Care Act and colloquially known as Obamacare, is a landmark U.S. federal statute enacted by the 111th United States Congress and signed into law by Pres ...
of 2010.
...intended to reduce unnecessary
health care costs Health, according to the World Health Organization, is "a state of complete physical, mental and social well-being and not merely the absence of disease and infirmity".World Health Organization. (2006)''Constitution of the World Health Organiz ...
through a variety of mechanisms, including: economic incentives for physicians and patients to select less costly forms of care; programs for reviewing the medical necessity of specific services; increased beneficiary cost sharing; controls on inpatient admissions and lengths of stay; the establishment of cost-sharing incentives for outpatient surgery; selective contracting with health care providers; and the intensive management of high-cost health care cases. The programs may be provided in a variety of settings, such as
Health Maintenance Organizations In the United States, a health maintenance organization (HMO) is a medical insurance group that provides health services for a fixed annual fee. It is an organization that provides or arranges managed care for health insurance, self-funded healt ...
and Preferred Provider Organizations.
The growth of managed care in the U.S. was spurred by the enactment of the
Health Maintenance Organization Act of 1973 The Health Maintenance Organization Act of 1973 (Pub. L. 93-222 codified as 42 U.S.C. §300e) is a United States statute enacted on December 29, 1973. The Health Maintenance Organization Act, informally known as the federal HMO Act, is a federal l ...
. While managed care techniques were pioneered by health maintenance organizations, they are now used by a variety of private health benefit programs. Managed care is now nearly ubiquitous in the U.S, but has attracted controversy because it has had mixed results in its overall goal of controlling medical costs. Proponents and critics are also sharply divided on managed care's overall impact on U.S. health care delivery, which ranks among the best in terms of quality but among the worst with regard to access, efficiency, and equity in the developed world.


History

Dr.
Paul Starr Paul Elliot Starr (born May 12, 1949) is a professor of sociology and public affairs at Princeton University. He is also the co-editor (with Robert Kuttner) and co-founder (with Kuttner and Robert Reich) of ''The American Prospect'', a notabl ...
suggests in his analysis of the American healthcare system (i.e., ''
The Social Transformation of American Medicine ''The Social Transformation of American Medicine'' is a book written by Paul Starr and published by Basic Books in 1982. It won the 1984 Pulitzer Prize for General Non-Fiction as well as the Bancroft Prize. Capers Jones wrote, "Paul Starr's book ...
'') that Richard Nixon, advised by the "father of Health Maintenance Organizations", Dr.
Paul M. Ellwood Jr. Paul Murdock Ellwood Jr. (July 16, 1926 – June 20, 2022) was an American physician and a controversial figure in American health care. Often referred to as the "father of the health maintenance organization", he not only coined the term, he a ...
, was the first mainstream political leader to take deliberate steps to change American health care from its longstanding not-for-profit business principles into a for-profit model that would be driven by the insurance industry. In 1973, Congress passed the Health Maintenance Organization Act, which encouraged rapid growth of Health Maintenance Organizations (HMOs), the first form of managed care.


Early origins

Before healthcare plans emerged, patients would simply pay for services out of pocket. In the period between 1910 and 1940, early healthcare plans formed into two models: a capitated plan (essentially an HMO), and a plan which paid service providers, such as the Blue Cross and Blue Shield Plans. One of the earliest examples is a 1910 "prepaid group plan" in Tacoma, Washington for lumber mills. Blue Cross (hospital care) and Blue Shield (professional service) plans began in 1929 with a prepaid plan with Baylor Hospital, spreading to other hospitals over the next several decades; these plans were largely independent of each other and controlled by statewide hospitals and physicians until the 1970s, when they became nonprofits before being converted into for-profit corporations such as Anthem.


1980s expansion and subdued inflation

Managed care plans are widely credited with subduing medical cost inflation in the late 1980s by reducing unnecessary hospitalizations, forcing providers to discount their rates, and causing the health care industry to become more efficient and competitive. Managed care plans and strategies proliferated and quickly became nearly ubiquitous in the U.S. However, this rapid growth led to a consumer backlash. Because many managed care health plans are provided by for-profit companies, their cost-control efforts are driven by the need to generate profits and not providing health care.The backlash against managed care
Nation's Business, July 1998, accessed 2007-10-05
In a 2004 poll by the Kaiser Family Foundation, a majority of those polled said they believed that managed care decreased the time doctors spend with patients, made it harder for people who are sick to see specialists, and had failed to produce significant health care savings. These public perceptions have been fairly consistent in polling since 1997. In response, close to 900 state laws were passed regulating managed care in the 1990s. The backlash featured vocal critics, including disgruntled patients and consumer-advocacy groups, who argued that managed care plans were controlling costs by denying medically necessary services to patients, even in life-threatening situations, or by providing low-quality care. The volume of criticism led many states to pass laws mandating managed-care standards. Meanwhile, insurers responded to public demands and political pressure by beginning to offer other plan options with more comprehensive care networks—according to one analysis, between the years 1970 and 2005, the share of personal health expenditures paid directly out-of-pocket by U.S. consumers fell from about 40 percent to 15 percent. So, although consumers faced rising health insurance premiums over the period, lower out-of-pocket costs likely encouraged consumers to use more health care. Data indicating whether this increase in use was due to voluntary or optional service purchases or the sudden access lower-income citizens had to basic healthcare is not available here at this time.


1990s growth and ubiquity

By the late 1990s, U.S. per capita healthcare spending began to increase again, peaking around 2002.The Factors Fueling Rising Healthcare Costs 2006
, report prepared by Price Waterhouse Coopers for
America's Health Insurance Plans AHIP (formerly America's Health Insurance Plans) is an American political advocacy and trade association of health insurance companies that offer coverage through the employer-provided, Medicare Advantage, Medicaid managed care, and individual ...
, January 2006, accessed 2007-10-05
Despite managed care's mandate to control costs, U.S. healthcare expenditures have continued to outstrip the overall national income, rising about 2.4 percentage points faster than the annual GDP since 1970. Nevertheless, according to the trade association
America's Health Insurance Plans AHIP (formerly America's Health Insurance Plans) is an American political advocacy and trade association of health insurance companies that offer coverage through the employer-provided, Medicare Advantage, Medicaid managed care, and individual ...
, 90 percent of insured Americans are now enrolled in plans with some form of managed care. ''The National Directory of Managed Care Organizations, Sixth Edition'' profiles more than 5,000 plans, including new consumer-driven health plans and health savings accounts. In addition, 26 states have contracts with MCOs to deliver
long-term care Long-term care (LTC) is a variety of services which help meet both the medical and non-medical needs of people with a chronic illness or disability who cannot care for themselves for long periods. Long-term care is focused on individualized and ...
for the elderly and individuals with disabilities. The states pay a monthly capitated rate per member to the MCOs that provide comprehensive care and accept the risk of managing total costs.


Techniques

One of the most characteristic forms of managed care is the use of a panel or network of healthcare providers to provide care to enrollees. Such integrated delivery systems typically include one or more of the following: * Designated doctors and healthcare facilities, known as a provider network, which enrollees are required or incentivized to useManaged Care: Integrating the Delivery and Financing of Health Care – Part A, Health Insurance Association of America, 1995, page 9 Margaret E. Lynch, Editor, "Health Insurance Terminology," Health Insurance Association of America, 1992, * Formal utilization review and quality improvement programs including disease management and case management * An emphasis on preventive care including wellness incentives and
patient education Patient education is a planned interactive learning process designed to support and enable expert patients to manage their life with a disease and/or optimise their health and well-being. Overview Education may be provided by any healthcare profes ...
The techniques can be applied to both network-based benefit programs and benefit programs that are not based on a provider network. The use of managed care techniques without a provider network is sometimes described as "managed
indemnity In contract law, an indemnity is a contractual obligation of one Party (law), party (the ''indemnitor'') to Financial compensation, compensate the loss incurred by another party (the ''indemnitee'') due to the relevant acts of the indemnitor or ...
".


Cost sharing

High-deductible health plan In the United States, a high-deductible health plan (HDHP) is a health insurance plan with lower premiums and higher deductibles than a traditional health plan. It is intended to incentivize consumer-driven healthcare. Being covered by an HDHP i ...
s are used by insurers to keep costs down by incentivizing consumers to select cheaper providers and possibly utilize less healthcare.
Reference price A reference price (RP) is the price that a purchaser announces that it is willing to pay for a good or service. It is used by high-volume purchasers to inform suppliers. RP requires consumers to have access to price and quality information, which i ...
schemes are another method to share costs, where a health insurer will only pay a certain amount and anything above that must be paid out of pocket.


Provider networks

Insurance plan companies, such as
UnitedHealth Group UnitedHealth Group Incorporated is an American multinational managed healthcare and insurance company based in Minnetonka, Minnesota. It offers health care products and insurance services. UnitedHealth Group is the world's seventh largest ...
, negotiates with providers in periodic contract negotiations; contracts may be discontinued from time to time. High-profile contract disputes can span provider networks across the nation, as in the case of a 2018 dispute between
UnitedHealth Group UnitedHealth Group Incorporated is an American multinational managed healthcare and insurance company based in Minnetonka, Minnesota. It offers health care products and insurance services. UnitedHealth Group is the world's seventh largest ...
and a major emergency room doctor group Envision Healthcare. Maintaining up-to-date provider directories is necessary as
CMS CMS may refer to: Computing * Call management system * CMS-2 (programming language), used by the United States Navy * Code Morphing Software, a technology used by Transmeta * Collection management system for a museum collection * Color manage ...
can fine insurers with outdated directories. As a condition of participation, UnitedHealthcare requires that providers notify them of changes, but also has a Professional Verification Outreach program to proactively request information from providers. However, providers are burdened by having to maintain their information with multiple networks (e.g., competitors to UnitedHealthcare). The total cost of maintaining these directories is estimated at $2.1b annually, and a
blockchain A blockchain is a type of distributed ledger technology (DLT) that consists of growing lists of records, called ''blocks'', that are securely linked together using cryptography. Each block contains a cryptographic hash of the previous block, ...
initiative began in 2018 to share the directory. When patients receive care from doctors who are out of network, they can be subject to
balance billing Balance billing, sometimes called surprise billing, is a medical bill from a healthcare provider billing a patient for the difference between the total cost of services being charged and the amount the insurance pays. It is an especially common pr ...
; this is particularly common in emergency or hospital care, where the patient may not be notified that a provider is out of network.


Utilization review

Utilization management Utilization management (UM) or utilization review is the use of managed care techniques such as prior authorization that allow payers, particularly health insurance companies, to manage the cost of health care benefits by assessing its appropriaten ...
(UM) or utilization review is the use of managed care techniques such as
prior authorization Prior authorization is a utilization management process used by some health insurance companies in the United States to determine if they will cover a prescribed procedure, service, or medication. The process is intended to act as a safety and co ...
that allow payers to manage the cost of health care benefits by assessing its appropriateness before it is provided using evidence-based criteria or guidelines. UM criteria are
medical guideline Medicine is the science and practice of caring for a patient, managing the diagnosis, prognosis, prevention, treatment, palliation of their injury or disease, and promoting their health. Medicine encompasses a variety of health care practic ...
s which may be developed in house, acquired from a vendor, or acquired and adapted to suit local conditions. Two commonly used UM criteria frameworks are the McKesson InterQual criteria and MCG (previously known as the Milliman Care Guidelines).


Lawsuits

In the 21st century, commercial payers were increasingly using litigation against providers to combat alleged fraud or abuse. Examples included litigation between
Aetna Aetna Inc. () is an American managed health care company that sells traditional and consumer directed health care insurance and related services, such as medical, pharmaceutical, dental, behavioral health, long-term care, and disability plans, ...
and a group of surgical centers over an out-of-network overbilling scheme and kickbacks for referrals, where Aetna was ultimately awarded $37 million. While Aetna has led the initiative, other health insurance companies have engaged in similar efforts.


Organizations

There is a continuum of organizations that provide managed care, each operating with slightly different business models. Some organizations are made of physicians, and others are combinations of physicians, hospitals, and other providers. Here is a list of common organizations: * Group practice without walls * Independent practice association * Management services organization * Physician practice management company (PPM)


Industry in the United States

As of 2017, the largest commercial plans were
Aetna Aetna Inc. () is an American managed health care company that sells traditional and consumer directed health care insurance and related services, such as medical, pharmaceutical, dental, behavioral health, long-term care, and disability plans, ...
,
Anthem An anthem is a musical composition of celebration, usually used as a symbol for a distinct group, particularly the national anthems of countries. Originally, and in music theory and religious contexts, it also refers more particularly to short s ...
,
Cigna Cigna is an American multinational managed healthcare and insurance company based in Bloomfield, Connecticut. Its insurance subsidiaries are major providers of medical, dental, disability, life and accident insurance and related products and se ...
, Health Care Service Corp,
UnitedHealthcare UnitedHealth Group Incorporated is an American multinational managed healthcare and insurance company based in Minnetonka, Minnesota. It offers health care products and insurance services. UnitedHealth Group is the world's seventh largest ...
, and Centene Corporation. As of 2017, there were 907 health insurance companies in the United States, although the top 10 account for about 53% of revenue and the top 100 account for 95% of revenue. Smaller regional or startup plans are offered by
Oscar Health Oscar Health, Inc. is an American health insurance company, founded in 2012 by Joshua Kushner, Kevin Nazemi and Mario Schlosser, and is headquartered in New York City. The company focuses on the health insurance industry through telemedicine, ...
,
Moda Health Moda Health (formerly ODS Health) is a health insurance company based in Portland, Oregon. The company provides medical and dental insurance in Oregon, Alaska and Texas (and in Washington state before 2016). The Moda Center, a sports arena that is ...
, and Premera. Provider-sponsored health plans can form integrated delivery systems; the largest of these as of 2015 was
Kaiser Permanente Kaiser Permanente (; KP), commonly known simply as Kaiser, is an American integrated managed care consortium, based in Oakland, California, United States, founded in 1945 by industrialist Henry J. Kaiser and physician Sidney Garfield. Kaiser Per ...
. Kaiser Permanente was the highest-ranked commercial plan by consumer satisfaction in 2018 with a different survey finding it tied with Humana. As of 2017, Medicaid and Medicare have become an increasingly large part of the private health insurance industry, particularly with the rise of Medicare Advantage programs. As of 2018, two-thirds of Medicaid enrollees are in plans administered by private companies for a set fee. These may involve some sort of value-based system; in addition, the contracted companies may be evaluated on
population health Population health has been defined as "the health outcomes of a group of individuals, including the distribution of such outcomes within the group". It is an approach to health that aims to improve the health of an entire human population. It ha ...
statistics, as in the case of California's
Medi-Cal The California Medical Assistance Program (Medi-Cal or MediCal) is California's Medicaid program serving low-income individuals, including families, seniors, persons with disabilities, children in foster care, pregnant women, and childless adults w ...
which tasked its companies with improving the health of its members.


Types

There are several types of network-based managed care programs. They range from more restrictive to less restrictive:


Health maintenance organization (HMO)

Proposed in the 1960s by Dr. Paul Elwood in the "Health Maintenance Strategy", the HMO concept was promoted by the
Nixon administration Richard Nixon's tenure as the 37th president of the United States began with his first inauguration on January 20, 1969, and ended when he resigned on August 9, 1974, in the face of almost certain impeachment because of the Watergate Scanda ...
as a fix to rising health care costs and set in law as the
Health Maintenance Organization Act of 1973 The Health Maintenance Organization Act of 1973 (Pub. L. 93-222 codified as 42 U.S.C. §300e) is a United States statute enacted on December 29, 1973. The Health Maintenance Organization Act, informally known as the federal HMO Act, is a federal l ...
. As defined in the act, a federally-qualified HMO would, in exchange for a subscriber fee (premium), allow members access to a panel of employed
physicians A physician (American English), medical practitioner (Commonwealth English), medical doctor, or simply doctor, is a health professional who practices medicine, which is concerned with promoting, maintaining or restoring health through th ...
or a network of doctors and facilities including
hospital A hospital is a health care institution providing patient treatment with specialized health science and auxiliary healthcare staff and medical equipment. The best-known type of hospital is the general hospital, which typically has an emergen ...
s. In return, the HMO received mandated market access and could receive federal development funds. They are licensed at the state level, under a license that is known as a certificate of authority (COA), rather than under an insurance license. In 1972, the National Association of Insurance Commissioners adopted the HMO Model Act, which was intended to provide a model regulatory structure for states to use in authorizing the establishment of HMOs and in monitoring their operations. In practice, an HMO is a coordinated delivery system that combines both the financing and the delivery of health care for enrollees. In the design of the plan, each member is assigned a "gatekeeper", a
primary care physician A primary care physician (PCP) is a physician who provides both the first contact for a person with an undiagnosed health concern as well as continuing care of varied medical conditions, not limited by cause, organ system, or diagnosis. The ter ...
(PCP) responsible for the overall care of members assigned. Specialty services require a specific referral from the PCP to the specialist. Non-emergency hospital admissions also require specific pre-authorization by the PCP. Typically, services are not covered if performed by a provider not an employee of or specifically approved by the HMO unless it defines the situation to be an emergency. Financial sanctions for use of emergency facilities in non-emergency situations were once an issue, but prudent layperson language now applies to all emergency-service utilization, and penalties are rare. Since the 1980s, under the
ERISA The Employee Retirement Income Security Act of 1974 (ERISA) (, codified in part at ) is a U.S. federal tax and labor law that establishes minimum standards for pension plans in private industry. It contains rules on the federal income tax e ...
Act passed in Congress in 1974 and its preemptive effect on state common law tort lawsuits that "relate to" Employee Benefit Plans, HMOs administering benefits through private employer health plans have been protected by federal law from malpractice litigation, on the grounds that the decisions regarding patient care are administrative rather than medical in nature. See '' Cigna v. Calad'', 2004.


Independent practice association (IPA)

An Independent Practice Association is a legal entity that contracts with a group of physicians to provide service to the HMO's members. Most often, the physicians are paid on a basis of capitation, which in this context means a set amount for each enrolled person assigned to that physician or group of physicians, whether or not that person seeks care. The contract is not usually exclusive so individual doctors or the group may sign contracts with multiple HMOs. Physicians who participate in IPAs usually also serve
fee-for-service Fee-for-service (FFS) is a payment model where services are unbundled and paid for separately. In health care, it gives an incentive for physicians to provide more treatments because payment is dependent on the quantity of care, rather than quality ...
patients not associated with managed care. IPAs usually have a governing board to determine the best forms of practices.


Preferred provider organization (PPO)

Rather than contract with the various insurers and third party administrators, providers may contract with preferred provider organizations. A membership allows a substantial discount below their regularly charged rates from the designated professionals partnered with the organization. Preferred provider organizations themselves earn money by charging an access fee to the insurance company for the use of their network (unlike the usual insurance with premiums and corresponding payments paid fully or partially by the insurance provider to the medical doctor). In terms of using such a plan, unlike an HMO plan, which has a copayment cost share feature (a nominal payment generally paid at the time of service), a PPO generally does not have a copayment but offers a deductible and a coinsurance feature. The deductible must be paid in full before any benefits are provided. After the deductible is met, the coinsurance benefits apply. If the PPO plan is an 80% coinsurance plan with a $1,000 deductible, the patient pays 100% of the allowed provider fee up to $1,000. The insurer will pay 80% of the other fees, and the patient will pay the remaining 20%. Charges above the allowed amount are not payable by the patient or insurer but written off as a discount by the physician. Because the patient is picking up a substantial portion of the "first dollars" of coverage, PPO are the least expensive types of coverage.


Point of service (POS)

A POS plan uses some of the features of each of the above plans. Members of a POS plan do not make a choice about which system to use until the service is being used. In terms of using such a plan, a POS plan has levels of progressively higher patient financial participation, as the patient moves away from the more managed features of the plan. For example, if patients stay in a network of providers and seeks a referral to use a specialist, they may have a copayment only. However, if they use an out of network provider but do not seek a referral, they will pay more. POS plans are becoming more popular because they offer more flexibility and freedom of choice than standard HMOs.


Private fee-for-service (PFFS)

There are basically two types of health insurance: fee-for-service (indemnity) and managed care. Policies may vary from low cost to all-inclusive to meet different demands of customers, depending on needs, preferences, and budget. Fee-for-service is a traditional kind of health care policy: insurance companies pay medical staff fees for each service provided to an insured patient. Such plans offer a wide choice of doctors and hospitals. Fee-for-service coverage falls into Basic and Major Medical Protection categories. Basic protection deals with costs of a hospital room, hospital services, care and supplies, cost of surgery in or out of hospital, and doctor visits. Major Medical Protection covers costs of serious illnesses and injuries, which usually require long-term treatment and rehabilitation period. Basic and Major Medical Insurance coverage combined are called a Comprehensive Health Care Plan. Policies do not cover some services.


Managed care in indemnity insurance plans

Many "traditional" or "
indemnity In contract law, an indemnity is a contractual obligation of one Party (law), party (the ''indemnitor'') to Financial compensation, compensate the loss incurred by another party (the ''indemnitee'') due to the relevant acts of the indemnitor or ...
" health insurance plans now incorporate some managed care features, such as precertification for non-emergency hospital admissions and utilization reviews. They are sometimes described as "managed indemnity" plans.


Impacts

The overall impact of managed care remains widely debated. Proponents argue that it has increased efficiency, improved overall standards, and led to a better understanding of the relationship and quality. They argue that there is no consistent, direct correlation between the cost of care and its quality, pointing to a 2002 Juran Institute study which estimated that the "cost of poor quality" caused by overuse, misuse, and waste amounts to 30 percent of all direct healthcare spending. The emerging practice of
evidence-based medicine Evidence-based medicine (EBM) is "the conscientious, explicit and judicious use of current best evidence in making decisions about the care of individual patients". The aim of EBM is to integrate the experience of the clinician, the values of t ...
is being used to determine when lower-cost medicine may in fact be more effective. Critics of managed care argue that "for-profit" managed care has been an unsuccessful health policy, as it has contributed to higher health care costs (25–33% higher overhead at some of the largest HMOs), increased the number of uninsured citizens, driven away health care providers, and applied downward pressure on quality (worse scores on 14 of 14 quality indicators reported to the National Committee for Quality Assurance). The most common managed care financial arrangement, capitation, places healthcare providers in the role of micro-health insurers, assuming the responsibility for managing the unknown future health care costs of their patients. Small insurers, like individual consumers, tend to have annual costs that fluctuate far more than larger insurers. The term "Professional Caregiver Insurance Risk" explains the inefficiencies in health care finance that result when insurance risks are inefficiently transferred to health care providers who are expected to cover such costs in return for their capitation payments. As Cox (2006) demonstrates, providers cannot be adequately compensated for their insurance risks without forcing managed care organizations to become price uncompetitive vis-a-vis risk retaining insurers. Cox (2010) shows that smaller insurers have lower probabilities of modest profits than large insurers, higher probabilities of high losses than large insurers, provide lower benefits to policyholders, and have far higher surplus requirements. All these effects work against the viability of healthcare provider insurance risk assumption.


Performance measurements

As managed care became popular,
health care quality Health care quality is a level of value provided by any health care resource, as determined by some measurement. As with quality in other fields, it is an assessment of whether something is good enough and whether it is suitable for its purpose. T ...
became an important aspect. The HMO Act in 1973 included a voluntary program of "federal qualification", which became popular, but over time this role was largely taken over by the
National Committee for Quality Assurance The National Committee for Quality Assurance (NCQA) is an independent 501(c)(3) nonprofit organization in the United States that works to improve health care quality through the administration of evidence-based standards, measures, programs, and ...
(NCQA), which began accrediting plans in 1991. Accreditation by the NCQA is often expected or require by employers. The
Healthcare Effectiveness Data and Information Set The Healthcare Effectiveness Data and Information Set (HEDIS) is a widely used set of performance measures in the managed care industry, developed and maintained by the National Committee for Quality Assurance (NCQA). HEDIS was designed to allow ...
(HEDIS) is a prominent set of measurements and reporting on it is often mandated by states as well as Medicare; as of 2017, HEDIS data was collected for plans covering 81% of the insured. Performance measurements can be burdensome on doctors; as of 2017, there were an estimated 900 performance measurements, of which 81 were covered by HEDIS, and providers used a combination of electronic health records and manual data entry to collect and report on the data. Aside from the NCQA, other organizations involved in quality include the
Joint Commission The Joint Commission is a United States-based nonprofit tax-exempt 501(c) organization that accredits more than 22,000 US health care organizations and programs. The international branch accredits medical services from around the world. A majori ...
,
URAC Headquarters and Offices The URAC offices are located in Washington, DC at 1220 L Street, NW. URAC is in the heart of the city, close to the White House, the Capitol and congressional offices and major transportation hubs. About half of URAC sta ...
, Physician Consortium for Performance Improvement (PCPI), and the
Agency for Healthcare Research and Quality The Agency for Healthcare Research and Quality (AHRQ; pronounced "ark" by initiates and often "A-H-R-Q" by the public) is one of twelve agencies within the United States Department of Health and Human Services (HHS). The agency is headquartered i ...
, with all these groups coordinating in the
National Quality Forum National Quality Forum (NQF) is a United States-based non-profit membership organization that promotes patient protections and healthcare quality through measurement and public reporting. It was established in 1999 based on recommendations by the ...
. A comparison of HEDIS metrics reported in 2006 and 2007 for Medicare Advantage and Medicare fee-for-service plans found a mixed picture.


Unmanaged care

The French healthcare system as it existed in the 1990s was cited as an "unmanaged" system, where patients could select their provider without the types of networks and utilization review found in the United States.


Opposition to Managed Care Schemes in Australia

In June 2021 Australian specialist doctors mounted a campaign to resist the introduction of US style managed care by health fund
nib Health Funds nib Group (nib, formerly Newcastle Industrial Benefits) is an Australian health care fund. It was established in the NSW Hunter Region in 1952 to provide health insurance for workers at the BHP Steelworks, and has since grown into a national and ...
in association with
Cigna Cigna is an American multinational managed healthcare and insurance company based in Bloomfield, Connecticut. Its insurance subsidiaries are major providers of medical, dental, disability, life and accident insurance and related products and se ...
.


See also

*
Healthcare in the United States The United States far outspends any other nation on health care, measured both in ''per capita'' spending and as a percentage of GDP. Despite this, the country has significantly worse healthcare outcomes when compared to peer nations. The Unit ...
*
Health insurance in the United States Health insurance in the United States is any program that helps pay for medical expenses, whether through privately purchased insurance, social insurance, or a social welfare program funded by the government. Synonyms for this usage include ...
*
Independent medical review An independent medical review (IMR) is the process where physicians review medical cases in order to provide claims determinations for health insurance payers, workers compensation insurance payers or disability insurance payers. Peer review also i ...
* Medical care ratio * Medicaid managed care *
URAC Headquarters and Offices The URAC offices are located in Washington, DC at 1220 L Street, NW. URAC is in the heart of the city, close to the White House, the Capitol and congressional offices and major transportation hubs. About half of URAC sta ...


References

{{DEFAULTSORT:Managed Care Health insurance Health care quality