Managed Care and Accountable Care Organization Improve the Quality of Care

Managed Care and Accountable Care Organization Improve the Quality of Care

Cost control is a significant concern for managed care organizations (MCOs). While attempting to maintain or raise patient care standards, MCOs adopt several cost-controlling methods. Utilization management, network management, and care coordination are a few methods by that MCOs control expenses (Colla & Fisher, 2017). Prior authorization, recent review, and case management are just a few of the strategies that MCOs use to ensure that healthcare resources are spent effectively. Utilization management allows MCOs to decrease pointless hospitalizations, tests, and operations, which helps to control expenses without sacrificing quality (Colla & Fisher, 2017).

Another strategy used by MCOs to control expenses is network management. They develop networks of preferred physicians and negotiate contracts with healthcare providers (CMS, 2018). MCOs can negotiate lower prices and cut healthcare expenditures by referring patients to these providers. MCOs work to avoid needless duplication of services and enable smooth transitions between healthcare providers by coordinating care across various healthcare locations and providers (CMS, 2018). Reducing pointless tests or treatments may result in better patient outcomes and cost savings.

My future career as an Advanced Practice Nurse (APN/APRN) would involve working with the MCO to deliver high-quality, affordable care. Working closely with the MCO’s utilization management teams, I would take part in case reviews, supply the relevant paperwork, and promote the use of methods supported by the best available evidence. I would help raise the treatment standard while adhering to the MCO’s cost-management measures by fusing clinical knowledge, research data, and patient preferences.

ACOs prioritize preventive care to control costs because it can delay the need for costlier interventions in the future. They also use care coordination and management techniques to cut down on pointless hospital stays, ER visits, and redundant treatments. Using evidence-based best practices, ACOs enhance outcomes and lower healthcare costs. My future responsibilities as an APN/APRN in an ACO include actively participating in care coordination initiatives, working with other healthcare professionals, and implementing evidence-based practices. By encouraging preventive care, conducting thorough assessments, and ensuring proper usage of healthcare resources, I would contribute to cost management (Mulvale et al., 2016).

In conclusion, both MCOs and ACOs use a variety of tactics to control spending without sacrificing the standard of care. Utilization management, network management, care coordination, and a focus on preventive care are some measures. Working with these organizations, promoting preventative services, care coordination, and evidence-based practice are all parts of my role as an APN/APRN in delivering cost-effective care.

References

Colla, C. H., & Fisher, E. S. (2017). Moving forward with accountable care organizations: some answers, more questions. JAMA internal medicine, 177(4), 527-528.

Centers for Medicare & Medicaid Services (CMS), HHS. (2018). Medicare Program; Medicare Shared Savings Program; Accountable Care Organizations–Pathways to Success and Extreme and Uncontrollable Circumstances Policies for the Performance Year 2017. Final rules. Federal Register, 83(249), 67816-68082.

Mulvale, G., Embrett, M., & Razavi, S. D. (2016). ‘Gearing Up to improve interprofessional collaboration in primary care: a systematic Review and conceptual framework. BMC family practice, 17(1), 1-13.

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In what ways does the MCO actually manage cost, and does it do so without diminishing the quality of care? How would your future role as an APN/APRN interface with the MCO?

 

In what ways does the ACO actually manage cost, and does it do so without diminishing the quality of care? How would your future role as an APN/APRN interface with the ACO?

Instructions: This is a discussion post, so a page to 1 1/2 pages is enough. APA format. Please use 3 references. Has to be at least three.