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Bhsh 402 - Managed Care and Case Management

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Managed care and case management

Tiara Moore



Anie Sklar

Managed care and case management

Managed care is structured around a variety of incentives to encourage the practice of cost-effective medicine, and to minimize variation in clinical practice pattern (Jecker, 1998). This can make the job of case management difficult because while being cost effective is important, client satisfaction is just as if not more important. This paper will discuss what managed care is, the role of the case manager and some services that can be impacted by managed care.

Managed care is care that is provided by the Health Maintenance Organization (HMO), the Preferred Provider Organization (PPO) and Point of service (POS) the intent is to limit the choices of providers, medical procedures and medications. The basis of managed care is to create a cost effective environment and according to Powell (2000), to hold the consumers, providers and payers accountable for the use of limited healthcare resources.

Case management according to the Certification of Insurance Rehabilitation Specialist Commission (CIRSC), "is a collaborative process which assesses, plans, implements, coordinates, monitors and evaluates opinions and services to meet an individual's health needs through communications and available resources to promote quality, cost effective outcomes" (Powell,2000). As a case manager in the mental health field, managed care can impact what services are provided to clients. Managed care can bring about stigma of cost effective over client effective, what may be good for the client may not be in the client's health plan. The case manger sometimes has to try to find the appropriate services needed for that client, and they have to go through the hectic task of trying to figure out what services are covered by their managed care provider. In some managed care plans mental health service has to be approved by their primary care doctor, which would require a certain amount of visits before a referral is made, which would include more out-of-pocket money from the client.

Case management services can be affected by managed care because of the billable services needed to get reimbursement. Treatments, procedures and medications has to meet the managed care protocol before funds are paid out. One of the things affected by managed care is mental health treatment plan. Mental health case managers have to implement these treatment plans for the client, the treatment plan is a layout of the client's progression of therapy. In doing the treatment plan sometimes the plan that the case manger has (which is beneficial



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