| Learn to coexist with and adapt to constant change. | Contract brings good/bad news of larger number of patients to supply but on one capitated cost. | Care provided under capitated contracts, less care that is needed the better. Thus health promotion important. |
| Once the initial insurance plan is negotiated, the consumer may have little say so as to the type and extent of services allowed and who will provide these services. | Vendors must learn to negotiate aggressively to be awarded managed care contracts. | Case managers become facilitators who are responsible for assuring continuity of care for the patient across acute and chronic disease episodes. |
| Physicians spend less time with activities that do not provide compensation. | Vendors "going at risk" (capitation) or heavily discounting fees for services. Many RNs will find fewer visits than needed paid for. | Not just in transition periods, but through-out the time the care is being delivered. MCOs have within their contracts expectations of response time, accessibility, etc. |
| Vendors attempt to reduce one of their largest expenses-labor costs. The use of ancillary personnel do not require licensed personnel. | Vendor's profit margins may be low. The vendor must operate very efficiently. This will challenge nurses' time and creativity | Coordinate the specific details during the transition. |
| Incentive to reduce health care costs and to demonstrate outcomes means equipment and supplies change and new telephone numbers and systems must be learned. | The home care vendor can be at risk of losing service fees unless they monitor appropriate utilization. | Population based case managers do have certain guidelines to follow, each patient's situation is unique and must be evaluated individually. |
| Transition of patients to other payers makes them suspicious they are not wanted. Patients may need to use cheapest supplies available. | Move toward a formulary of equipment and supplies. The use of a formulary is not a new concept. | Case managers might help the patient obtain financial relief by working with the out-of-network provider to arrange lower coinsurance or a lower rate. |
| More primary care NPs and MDs are managing therapies that they would have traditionally referred to specialists. | Acceptance of cost effective approaches by patients is variable. | Disease state management programs, such as asthma, diabetes, women's health, and varies nontraditional various health approaches are used. |
| Relationships with clinicians are lost, changed because patients/family members become their own case and disease state managers | Productivity measures: Specified visit times, outcome reports, and patient satisfaction surveys are used. | Patient opinion is also evaluated as part of the decision-making process. Employers (e.g. Hedis) and the public in general hold managed care plans accountable. |
Comments added by Sue Beckel, RN, BSN, Certified Care Manager, Vice President of Health Care Services, Qual Choice, Cleveland, OH; Laurie Herberick, Editorial Assistant ASPEN, Silver Spring, MD; Marsh Orr, RN, MS, CS, Regional Manager, Apria Health Care Inc., Phoenix, AZ; and Kathy Crockerm RN, TPN Clinics, WMC Home Care Senior Management.
Your assignment is to read the previous table clinical situation and identify one conflicting patient, clinician and managed care organization point of view. Describe the points of view and potential approaches to conflict resolution. Use the text box below to complete this assignment.
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