Managed care is under tremendous scrutiny. As we embark on a new millennium, a majority of states and the federal government have managed care reform legislation under debate. The central focus of the reform is patients’ rights and protection. The legislation advocates for the right of patients to sue managed care organizations (MCOs) for death or injury sustained from poor care or denied treatment. Patient protection clauses include the freedom of choice, the freedom to access urgent care, and the freedom to receive whatever care is necessary in light of a life-threatening illness (Kongstvedt, 2003).
Why Managed Care Legislative debate on how to accomplish health care reform continues on a Federal level. This debate centers on whether access to quality health care should focus on individuals based on income (e. g. , the working poor) or by age (e. g. , the elderly). Also, states are proposing innovative health care reforms, particularly those aimed at uninsured children and families. For example, the state of Arkansas proposed ‘Kids First’, a preventive health benefit package aimed at children in poverty.
Florida is trying to expand their state subsidized health insurance program entitled available through school systems. In addition, South Carolina introduced a bill that would require the state to cover the cost of emergency services for children. Kentucky, Minnesota, Connecticut and Colorado enacted significant health care reform legislation but must overcome major hurdles posed by the Employee Retirement Income Security Act (ERISA) of 1974 before enacting their laws.
However, Florida, New York, Tennessee, Texas and Oregon are all implementing health care reform legislation passed since 1989. For example, the state of Oregon set the benchmark for universal coverage by extending health services to a large number or residents. Under Oregon’s coverage, more individuals are in Medicaid managed care plans with a prioritized list of medical conditions that will be covered. According to Bodenheimer (1997), only 565 of the 696 medical conditions normally covered by Medicaid are paid by the State.
Among the industrialized nations, the United States is the only country that relies on both the private markets and the public sectors to determine the type, quality and amount of medical care provided. Other nations allow governments to intervene and play a lead role in determining the cost and type of medical care. Taxes fund the medical costs, and all citizens, regardless of whether or not they are in the work force, are eligible for health care. However, each country developed a different way to control costs (Rickel & Wise, 1999). Summary and Conclusion
With the expansion of managed care, pharmacists and other health care professionals have supported the introduction and enactment of legislation that would prevent them from being excluded from participation. This legislation has taken one of two forms: 1) MCOs may not deny a non-network pharmacy from joining the network if the pharmacy is willing to accept the terms of participation (called any-willing-provided legislation), or 2) MCO enrollees may select any pharmacy (called freedom-of-choice legislation) (McCarthy & Schafermeyer, 2004).
We cannot escape the conclusion that if we are to care for the poor, the very young, the very old, the frail and the handicapped, some sacrifice of privilege, personal satisfactions, and discretionary expenditure is necessary. Throughout any discussion of managed care reform, the patient has to be our number one concern. We have to remember that those who are ill and need medical treatment are the most vulnerable among us. They need and deserve these protections (Bondeson & Jones, 2002).