Unfortunately, managed care is not a well-defined single entity. There is no universal set of standards. However, the organizations and reimbursement models that comprise managed care systems share the objective of controlling costs through utilization management and, generally, of improving preventive care. Managed care can be defined as a diverse, constantly changing set of interrelated policies and procedures designed to manage the accessibility, quality, utilization and cost of healthcare services.
Increasingly, managed care objectives involving public funds reflect a strong effort to address community-specific population needs and therefore target in state regional and county level structures, goals, and funding mechanisms.
The primary tenets of managed care are being accomplished with widely divergent degrees of success. These goals are to:
- Identify, reduce or eliminate unnecessary and/or inappropriate care ("no more, no less" than medically necessary)
- Reduce variability of treatment
- Reduce length of stay/treatment or shift the locus of care from institutions to community settings
- Direct patients to the least restrictive and most cost effective program
- Improve the efficiency and efficacy of treatment
- Identify and eliminate or reduce ineffective services
- Improve preventive care
- Reduce excess capacity of provider organizations
- Improve management of mental health services
- Utilize defined admission, continuing care, and discharge criteria
- Identify optimal clinical pathways based on outcomes
- Control clinical and administrative expenses
- Reduce cost to client and third party payers
- Assure a minimum standard for quality and effectiveness of care
- Assure an appropriate continuum of care throughout the provider network
In order to determine your information management requirements for managed care it is necessary to understand the features of the managed care plans in which your organization will participate as a provider.
The challenge of this endeavor is that no universal standards for managed care exist. To complicate matters further, the various derivatives of managed mental health plans are continuously changing as consumers, providers, sponsors and managed care organizations become more sophisticated.
Over the past decade a variety of cost containment strategies have evolved and components of all three are still in place in most managed care contracts. Freedman (1995), identifies three general cost management strategies that have been used by managed care organizations: benefit management, care management and health management. All of these strategies and the techniques employed have had a major impact on management information systems.
About The Authors:
Bruce Johnson, M.S., PMP, is President of Johnson Consulting Services, Inc., an information management consulting firm that specializes in working with social service, healthcare, and government organizations. He can be reached at (800) 988-0934, www.jcsconsultants.com or by e-mail at jcsinc@fuse.net. Mr. Schafer is a clinical records and operations management consultant. He specializes in working with managed care, behvavioral healthcare and child welfare organizations. He can be reached at (800) 661-2435, www.schaferconsulting.com or by e-mail at steve@schaferconsulting.com.
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