MANAGED CARE PROGRAMS Meaning and
Definition
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Managed care programs are a type of healthcare delivery system that aim to efficiently manage the provision of healthcare services while controlling costs. These programs involve the coordination of healthcare services for individuals, often through a network of healthcare providers and facilities, to ensure appropriate and cost-effective care.
The primary objective of managed care programs is to promote high-quality healthcare while minimizing unnecessary medical expenses. These programs typically involve contracts between healthcare providers and insurers, wherein the providers agree to deliver healthcare services to the members of the program in exchange for payment from the insurer. By establishing networks of participating providers, managed care programs seek to control costs by negotiating discounts and setting predetermined fees for services.
Managed care programs often employ a range of strategies to manage healthcare services, such as utilization review, case management, and gatekeeping. Utilization review involves assessing the necessity and appropriateness of medical services to avoid unnecessary treatments or procedures. Case management involves coordinating care for individuals with complex healthcare needs. Gatekeeping refers to a system in which primary care physicians act as gatekeepers, requiring referrals for specialty care to ensure appropriate utilization of healthcare services.
Overall, managed care programs aim to balance cost containment, quality improvement, and access to healthcare services. They play a significant role in shaping modern healthcare delivery systems by providing a framework to efficiently manage and coordinate healthcare services, with the ultimate goal of delivering effective and affordable care to participants.
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