Managed care fundamentals: implications for health care organizations and health care professionals.

Abstract

Managed care is changing our health care delivery system as radically as the computer chip has changed telecommunications. Health care professionals and organizations that do not understand managed care's implications will not be prepared for the future. For example, one implication of managed care is payment capitation, which is the transfer of financial risk from the insurer to the provider. As a result, health care providers, including occupational therapy professionals, need to be better managers of scarce resources by recognizing the cost implications among various alternative procedures while still delivering quality care. Under managed care with capitation, occupational therapists will need to learn to provide services within the parameters of a fixed budget, requiring reengineering of the therapies and processes of care and a considerable reduction in the procedures and modalities for any given treatment or therapy. As a result, patients will be required to do more for themselves, and occupational therapists will have to become better patient educators and motivators. Additionally, managed care will require changes in professional curriculums, emphasis through continuing education, and assimilation of better cost information to practitioners to facilitate decision making. Implications of managed care other than payment capitation are assigning to enrollees a gatekeeper who is responsible for limiting access to costly specialty services, practicing utilization review to audit usage patterns and provide constructive recommendations to reduce costs and improve service quality, and forming networks and associations among medical providers for developing economies of scale and providing an integrated continuum of health care services to enrollees.