Saturday, November 13, 2010

The Way How Care Is Showed part ii

This post is actually a continuation of my previous post, "The Way How Care Is Shows" as health Insurance and Managed Care have are technically correlate to one another. The root of the topic tree for me to elaborate here is,



Referring to Bashir Mamdani, Meenal Mamdani in the book of "Managed Care in the USA: History and Structure", managed care combines financing and delivery of health care in a single entity with the aim of improving quality of care while controlling costs.

After listened to the lecture given by Mr. Gatot Subroto (PT.Askes KCU Yogyakarta) and through further reading about it, I understand managed care as a system that controls the financing and delivery of health services to members who are enrolled in a specific type of health care plan. Read further as I'm giving the examples and explanations of the plans provided for a better understanding about this thing:)

 What's the purpose? Any GOALS to set up to?

To ensure that:
  • providers deliver high quality care in an environment that manages or controls costs.
  • the care delivered is necessary and appropriate for the patient’s condition.
  • care is provided by the most appropriate provider and settings.
In general: To eliminate inappropriate tasks and ensure that cost effective practice is adapted.

How does it works?

Briefly say, managed care works through modifying the actions of doctors (or other professionals initiating care) to reach its goals.

Do managed care have any level of its implementation or success?

It's measured in a way of growth of its maturity from 1st Generation to 5th Generation.

Main points


i.    Retrospective utilization review
Doctors do something --> they review it --> they correct it

ii. 2nd opinion programme
Comparing one provider to another

Eg. Dr Taufiqah is having a patient with a heart problem. She discussed it with Dr Nazshua and he suggested that the patient needs an open heart surgery. Dr Taufiqah then asked Dr Djoko who had been a cardiologist for 20 years to get his opinion. Dr Djoko will do the examination and he’ll decide the management.


Increase use of capitation and gatekeeper (Primary Care Provider) by ensuring that the reference system is really works.


          i.      Management of high cost cases

        ii.      Providing or profiling
Eg. Comparing one Rumah Sakit to another Rumah Sakit of the same class level.

      iii.      Clinical practice Guidelines


          i.      Increasing interest in health outcomes
        ii.      Health plan report cards (league)
      iii.      Health system integration
      iv.      Improved information system and system monitoring


        i.         Anticipatory case management
      ii.         Targeted disease management
    iii.         Outcomes- based reimbursement
    iv.         Community- based needs assessment

*The examples I gave are based on my understanding by what the guest lecturer conveyed. Please correct me if I'm wrong. Thank you very much*
  • ASKES in Indonesia are now reaching between the 3rd to 4th Generation.
  • The 4th Generation features are now developing in US.

What are the major types of Managed Care plans?

Health Maintenance Organizations (HMO)
Preferred Provider Organizations (PPO)
Point of Service (POS)

HMO + Health care providers
--> “Provider Network”

A contracted provider provides services to health plan members at discounted rate in exchange for receiving health plan referrals.

PPO + Health care providers
--> “Provider Network”

POS + Health care providers
--> “Provider Network”

Members must only see providers within this network to have their health care paid by the HMO.

Members have no gatekeeper nor do they have to use an in- network provider for their care.

1.Often called an HMO/ PPO hybrid or an “open- ended” HMO
2.It’s called “point- of- service”:
Members choose which option (HMO or PPO) they will use each time they seek health care.

Members select a Primary Care Physician (PCP) i.e. the gatekeeper.
Offers members “richer” benefits as financial incentives.

Eg. If Miss Taufiqah sees an in- network family physician for a routine visit, she only has a small co- payment or deductible. If she sees a non- network family physician, she has to pay as much as 50% of the total bill.

Encourage, but don’t require members to choose a PCP.
Most restrictive because providing members the least choice in choosing a provider.
Less restrictive than HMOs in the choice of health care providers.
Offers more flexibility and freedom of choice.

Provide members with a greater range of health benefits for the lowest out- of- pocket expenses.

Require greater out- of- pocket payments from the members.

Members who choose not to use their PCPs for referrals (but still seek care for an in – network provider) still receive benefits but will pay higher copays and/ or deductible than members who use their PCPs.

All of all, this intended to reduce the cost of providing health benefits and improve the quality of care :)

Frankly speaking, before I had a discussion about this, I actually confused on how POS really works. Reading alone 2, 3 times made me dizzier@_@ Hence, a bunch of THANKS to my group members (Group 8 For The Win~) for giving a good explanations about it during the tutorial sessions and to our tutor, dr. Luthfan Lazuardi for the kind assistance.


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