Discussion 1 (Kayla)
According to Heaton (2023), Managed Care Organizations (MCO) started in the 1970’s. The primary focus is to reduce healthcare costs. The Health Maintenance Organization Act of 1973 established the foundation for managed care organizations and the utilization of cost-saving methods There are a variety of MCO’s, including health maintenance organizations (HMOs), preferred provider organizations (PPO), and point of service (POS) organizations.
With the different types of managed care organizations, they also come with different regulations regarding care. Therefore, I feel it is beneficial to have that specific managed care organization educated on how to interpret performance data. There are many ways that education can be provided. This can include literature that is appropriate to understand for different levels of literacy as well as video resources. This information can be readily available on their websites for easy access and review. The utilization of managed care organizations has improved patient outcomes while reducing expenses due to providing cost-effective management (Heaton, 2023).
There can be benefits and disadvantages when it comes to making performance data information available to the public. I found the article “Mechanisms and Impact of Public Reporting on Physicians and Hospitals Performance (2021). Ultimately, the utilization of performance data strives to improve health outcomes by promoting quality improvement. The article consisted of studies between 2000-2020 and divided into user and provider responses to public performance reporting and the impact of public performance reporting on quality of care provided (Prang et al., 2021). “Most of the studies reported positive effects of PPR on the selection of providers by patients, purchasers and providers, quality improvement activities in primary care clinics and hospitals, clinical outcomes and patient experiences” (Prang et al., 2021, p.1, para 4). For providers that are providing quality care, the publicly available performance data can help acquire more patients. However, if a managed care organization is associated with poor performance data this can lead to poor access to quality care for their subscribers.
Discussion 2 (Maria)
Managed care organization (MCO) should provide “health plan performance data” to its subscribers to enhance the selection between various health plans offered. The data contains measures including: 1) effectiveness of care, 2) access/availability of care, 3) experience of care, 4) health plan descriptive information, and others (Sultz & Young, 2017, p. 215).
As it may be a close choice between two plans or more for many subscribers, additional information allows subscribers to differentiate between them and make a decision that serves their interest, rather than guessing and later regretting their choice. Subscribers’ can access data including patient outcomes, compliance with national standards for preventive and chronic care, and comparative cost in services.
MCOs and employers should not only be obligated to educate subscribers to interpret performance data, but also take responsibility for the expenses incurred for such education. It is an employer’s duty to provide necessary information to their employees which allows them to make an informative decision on matters that can impact their wellbeing.
Having performance data available to the public may be beneficial to subscribers. It allows them to take responsibility and ownership of their decisions. It also enhances appropriate utilization of health services and improve patient care and outcomes. Patient Reported Experience Measures (PREMs) are obtained by direct surveys which are aimed to better patient outcomes and to improve quality and safety (Gilmore et al., 2022). Being more informed on the cost, subscribers will be more cognizant on the use of health services including ER coverage, lab work, prescription, and others. They may utilize urgent care versus ERs. Also, it can increase health promotion when they opt to schedule an appointment with their primary care providers rather than wait until their health becomes emergent, requiring a visit to the ER.
In contrast, access to performance data can have disadvantages for subscribers in the community. Some subscriber’s inability to interpret and understand performance data can potentially lead to their frustration; resulting in poor decision making with their health plan selections. Subscribers may not take into account that some performance data may contain incomplete data. In a study of Medicaid expansion and MCO enrollee experience, Nguyen et al. (2022), found special consideration is necessary since the performance metrics obtained had incomplete data of patient reporting in the surveys. Also, having information about health providers, subscribers may lose trust in their healthcare providers or institutions. It can negate seeking medical advice and decrease utilization of primary care or health institutions.
