Historical Perspectives of Health Care Services Delivery
Historical Perspectives of Health Care Services Delivery Health care cost has risen dramatically due to advancements in technology, proliferation of medical specialty, inflation, growth of aging population, and desires and demands of service users. In order to control the health care costs without jeopardizing the quality and access of care, the health care delivery system has been continuously changed, resulting in the increased independent specialty practices and the growth of managed care plans (DeNavas-Walt, Proctor, & Smith, 2007).
Such plans include Health Maintenance Organizations (HMOs), Preferred Provider Organizations (PPOs), and Point of Service (POS). Managed care plans are defined as health insurance plans that contract with health care providers and facilities to provide necessary and efficient health care for members at appropriate costs (MedlinePlus, 2010). Recently, state and federal governments have turned to managed care to help with the Medicaid and Medicare programs.
In 1990s, the managed care plans controlled overall health care spending by using the primary care physician as their gatekeepers to limit access to specialists and expensive procedures (Jones & Johnson, 2006). HMOs restricted recommended care by utilization review. In addition, payments were based on the diagnosis regardless of the actual period of treatment or hospitalization. This encouraged hospitals and physicians to reduce the length of hospital stay.
These changes created new ethical issues, such as encouraging physicians to provide only minimal obligated care to decrease expense and rejecting some applicants with potentially expensive chronic illnesses (Orszag & Ellis, 2007). . In the managed care environment, nurses can take expanded roles of a care manager, a utilization review nurse, a risk manager, or a quality officer in various healthcare settings as well as the traditional roles of a direct patient care nurse, a nurse educator, and a nurse administrator.
Care managers manage patient needs and coordinate resource and care provided by other health providers. Utilization review nurses review the patient’s care and influence decisions about treatment. Risk managers work to reduce the adverse outcomes related to patient care by identifying risk factors, implementing corrective actions, and developing strategies to decrease risk. Quality officers are in charge of performance improvement, outcome management, and health care research activities (American Nurses Association, 2011)