Managed Care System

By the end of 1994, roughly 60 percent of physicians joined at least wholeness health maintenance organization (health maintenance organization); radiologists have the greatest participation. At the beginning of managed sustenance, growth was greatest in preferred provider organizations (PPOs). Physicians in PPOs contract with networks and agree to provide services for discounted fees. give habits do not fate to change and physicians have no incentive to limit patient visits or procedures. Although this provided advantages to the patient and the physician, the mode changed to the HMO do produce further savings (Friedenberg, 1996).

Managed constituted coverage is a system in which patients or physicians must obtain prior authorization for hospitalization and expensive outpatient services. For PPOs cognise as point of service arrangements, insurance companies pay a standard negotiated fee. If the patient enjoyments a preferred physician or hospital, the fee is paid with a small or no copayment; otherwise the PPO usually pays 80 percent. HMOs require the patient to use a doctor or hospital included in the HMO. It is predicted that in the future, HMOs will cover the majority of the nonelderly population (Sunshine & Evens, 1994).

Managed cover has two goals in particular, to control health fright be and to provide quality services that are sufficient copious to satisfy the enrollees. Several strategies based on direct con

Friedenberg, R. M. (1996). Managed care: The reality must be controlled. Radiology, 198 (3), 45A-47A.

Nurse care models are changing with the advent of managed care; many nurse leaders believe that controlling cost is more important than maximum reimbursement for tasks. With this priority, care models will be focuses on makeiveness and efficiency to support competitive pricing. lumber changes in the nurse care delivery system motivating to include the following: adequate educational preparation; medical specialist levels of autonomous functioning in non-institutional settings; defined duties; and interdependent and cooperative efforts to work with other nurses (Girard, 1993).

Measures of quality of managed care are interracial; measures include process and outcomes criteria. The quality of care is generally entrap to be comparable in HMO and fee-for-service settings. Evidence shows that HMO enrollees receive more preventive tests, procedures, and examinations than those in fee-for-service settings; outpatient care expiation is rated lower in HMOs. Direct studies of effects of managed care on care provided to diabetics have been done. Capitation, copayments, and deductibles limit the use of services, particularly inmate hospital care. Payment incentives encourage routine initiation of insulin therapy on an outpatient basis, but this adversely affects the care of those who would benefit from inpatient care. It is believed that managed care will adversely affect the care of more labyrinthine diabetic patients, however, some aspects of care will improve since handiness of structured programs is higher in HMOs (Quickel, 1996).

Response to these changes is important to consider. Radiologists and others need to respond in a way that is helpful to patients and their profession. limited issues, that tend to have adverse effects of quality, need to be addressed. Self-referral tends to generate excessive utilization and costs which has an adverse effect on
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