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Managed care is a concept in U.S. health care.
Managed care is based on a effort to control escalating health care costs. There are several forms of managed care. Ranging from the more restrictive to the least, they include:
- Health Maintenance Organizations (HMOs): Proposed in the 1960s by Dr. Paul Elwood in the "Health Maintenance Strategy", the HMO concept was promoted by the Nixon Administration as a fix to the escalating health care costs and set in law as PL 93-222. As defined in the act, a federally qualified HMO would in exchange for a subscriber fee (premium) allow members acess to panel of employed physicians or a network of doctors and facilities including hospitals. In return the HMO received mandated market access and could receive federal development funds. In the design of the HMO each member was assigned "gatekeeper", a primary care physician (PCP) who was 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 required specific pre-authorization. Typically, out-of-network services are not covered unless it is an emergency or the care needed is not available in-network and the member has received prior authorization for such care. Financial sanctions for use of emergency facilities in non-emergent situations were once an issue; however, prudent-layperson language now applies to all emergency-service utilization and penalties are rare. A leading example is the Kaiser-Permanente Plan.
- Preferred Provider Organizations (PPOs): Insurance-based product in which insureds receive more generous benefits (possibly including lower deductibles, lower copayments, and higher reimbursement percentages) if a pre-approved "network" of physicians and facilites is utilized in non-emergency situations. Review of emergency facility usage for evidence of medical necessity. "Pre-certification" (prior approval) required before nonemergency hospital admissions or outpatient surgery.
- Point of Service (POS): A plan utilizing some of the features of each of the above plans. (needs better definition)
In addition, many "traditional" or "indemnity" health insurance plans now incorporate some managed care features such as precertification for non-emergency hospital admissions and utilization reviews.
The rise of managed care was credited for the lessened rate of medical inflation seen in much of the 1990s in the U.S., which in some years of that decade the rate of increase in price of medical goods and services was little more than the overall rate of general inflation. However, this effect now seems to largely have ended, and U.S. medical inflation is once again two or three times the rate of overall inflation, as it was during much of the 1980s.
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