Managed Care in the U.S. Health Care System
In 2010, the Affordable Care Act (ACA) was enacted to expand access to care, make coverage more affordable, and reduce the number of uninsured. By 2014, approximately 77% of Medicaid recipients had signed up for various forms of managed care. Moreover, it is a requirement that for a hospital to participate in the ACA program, it has first to be accredited and certified by a certification body, such as the Joint Commission and the Center for Improvement in Healthcare Quality. Although accreditation is voluntary, all hospitals participating in the ACA program are required to meet the minimum set standards that have been established by the accreditors.
Therefore, this helped ensure the quality of services provided. The inception of the ACA revolutionized the U.S. healthcare insurance sector in several ways. For instance, ACA provisions resulted in health payers increasing their spending, and consequently, to account for it, payers had to narrow their provider networks. This led to the escalation of out-of-pocket costs and premium rates. This adverse effect of the ACA has led to many managed care state programs starting to shift towards value-based payments. This is because the various governments have realized that a limited number of physicians are participating in the Medicaid program; thus this makes it hard for consumers to have proper access to care. Challenges of access to care are further increased when competing for Medicaid-managed care plans further constrict the physician networks within their policies.
Furthermore, unlike previous health reforms, the ACA has expanded to cover preventive services, such as immunizations and cancer screenings. Due to increased expenditure, state governments are starting to change their contracting strategies. They are more inclined towards embracing outcomes-based contracts in which base payments rely on the achievement of excellent patient outcomes in a predetermined patient population, rather than the traditional contracting strategies in which the base payment was centered on the volume of medication sold.