Group Medical Expense Benefits, Managed Care Plans - Quality of Care

A difficult question to answer is whether persons covered by managed care plans receive the same quality of care as persons covered under traditional medical expense plans. If the sole objective of a managed care plan is to offer coverage at the lowest possible cost, there may be a decline in the quality of care. However, some type of quality assurance program is one aspect of any managed care plan. If properly administered, this type of program can weed out providers who give substandard and unnecessary care. In this regard, managed care plans may be more progressive than the medical field as a whole.

The results of numerous surveys and studies on the quality of medical care plans have been mixed. Some studies show that persons in managed care plans are less likely than persons in traditional medical expense plans to receive treatment for a serious medical condition from specialists, and they are also likely to have fewer diagnostic tests. There are those who argue that family physicians can treat a wide variety of illnesses and avoid unnecessary diagnostic tests and referrals to specialists. On the other hand, an opposing argument contends that the decline in the use of specialists and frequency of diagnostic tests is also a clear indication that there is a decline in the level of medical care. Other studies show that persons in managed care plans are much more likely than the rest of the population to receive preventive care and early diagnosis and treatment of potentially serious conditions such as high blood pressure and diabetes. In addition, managed care plans are viewed as having been successful in coordinating care when it is necessary for a person to see several different types of specialists. There is no doubt that there are some small provider networks with a limited choice of specialists, but most networks are relatively large or allow persons to select treatment outside the network. There are also many managed care plans that do refer patients to highly regarded physicians and hospitals or have these providers as part of their networks.

In evaluating the quality of medical care, it is also interesting to look at surveys of participants in the various types of medical expense plans. Most persons in traditional medical expense plans are convinced they receive better care because of their unlimited ability to choose providers of medical care as needed. While surveys of participants in managed care plans usually show a high degree of satisfaction with the medical care received, there are some concerns that have resulted in recent plan changes and legislative actions and interest.

Two recent developments relate to the quality of care provided by managed care organizations—an increased interest in accreditation and a consumer backlash against some aspects of managed care. This backlash has led to the introduction or passage of laws in many states aimed at solving consumer and provider concerns about access to care, quality of care, and choice.