| 释义 |
managed care
man·aged care (măn′ĭjd)n. Any arrangement for health care in which an organization, such as an HMO, another type of doctor-hospital network, or an insurance company, acts an intermediary between the person seeking care and the physician.man′aged care′
n. a health plan or system that seeks to control medical costs by contracting with a network of providers and by requiring preauthorization for visits to specialists. [1985–90] TranslationsEncyclopediaSeecaremanaged care
care [kār] the services rendered by members of the health professions for the benefit of a patient. See also treatment" >treatment.acute care see acute care.admission care in the nursing interventions classification, a intervention" >nursing intervention defined as facilitating entry of a patient into a health care facility.adult day care a health care service provided for adults with a disability or illness who need partial or supplemental care and companionship during the day, when family members are working or otherwise unable to stay at home with a disabled relative. Among the services that may be offered at an adult day care center are nursing services (e.g., medication administration and health monitoring); nutritional and health education, health counseling; physical, speech, and occupational therapy; and socialization.ambulatory care health services or acute care services that are provided on an outpatient basis.amputation care in the nursing interventions classification, a intervention" >nursing intervention defined as the promotion of physical and psychological healing after amputation" >amputation of a body part.bed rest care in the nursing interventions classification, a intervention" >nursing intervention defined as promotion of comfort and safety and prevention of complications for a patient unable to get out of bed. See also bed rest.bladder care activities and interventions designed to maintain urinary bladder function, including bladder retraining, catheter change, and catheter irrigation.bowel care activities and interventions designed to maintain bowel function, including enema, bowel training, diet, and medication.bowel incontinence care in the nursing interventions classification, a intervention" >nursing intervention defined as promotion of bowel continence and maintenance of perianal skin integrity.bowel incontinence care: encopresis in the nursing interventions classification, a intervention" >nursing intervention defined as promotion of bowel continence in children.cardiac care in the nursing interventions classification, a intervention" >nursing intervention defined as the limitation of complications resulting from an imbalance between myocardial oxygen supply and demand for a patient with symptoms of impaired cardiac function.cardiac care: acute in the nursing interventions classification, a intervention" >nursing intervention defined as the limitation of complications for a patient recently experiencing an episode of an imbalance between myocardial oxygen supply and demand resulting in impaired cardiac function.cardiac care: rehabilitative in the nursing interventions classification, a intervention" >nursing intervention defined as the promotion of maximal functional activity level for a patient who has suffered an episode of impaired cardiac functon which resulted from an imbalance between myocardial oxygen supply and demand.cast care activities and interventions designed to protect and maintain an immobilized body part, including relief of pain, pressure or constriction of circulation. See also hazards of immobility.cast care: maintenance in the nursing interventions classification, a intervention" >nursing intervention defined as care of a cast after the drying period.cast care: wet in the nursing interventions classification, a intervention" >nursing intervention defined as care of a new cast during the drying period.cesarean section care in the nursing interventions classification, a intervention" >nursing intervention defined as the preparation and support of a patient delivering a baby by cesarean section" >cesarean section.circulatory care: arterial insuficiency in the nursing interventions classification, a intervention" >nursing intervention defined as promotion of arterial circulation.circulatory care: mechanical assist device in the nursing interventions classification, a intervention" >nursing intervention defined as temporary support of the circulation through the use of mechanical devices or pumps.circulatory care: venous insufficiency in the nursing interventions classification, a intervention" >nursing intervention defined as promotion of venous circulation.contact lens care in the nursing interventions classification, a intervention" >nursing intervention defined as the prevention of eye injury and lens damage by proper use of contact lenses.continuing care the level of care in the health care system that consists of ongoing care of the physically handicapped, mentally retarded, emotionally retarded, and those suffering from chronic incapacitating illness.cord care specialized care of the remnants of a newborn's umbilical cord" >umbilical cord until it falls off, consisting of cleaning and precautions to prevent infection. Cleansing protocols continue until the site is completely healed.critical care intensive care.culture-specific care those assistive, supportive, or facilitative acts toward or for an individual or group with evident or anticipated needs that are congruent with the values and lifestyles of an individual, family, or group of a specific culture, as used in the cultural care diversity and universality theory.day care/respite in the omaha system, the providing by an individual or institution of supervision for a dependent child or adult in the abscence of the usual caregiver or parent.developmental care in the nursing interventions classification, a intervention" >nursing intervention defined as structuring the environment and providing care in response to the behavioral cues and states of the preterm infant.direct care the provision of services to a patient that require some degree of interaction between the patient and the health care provider. Examples include assessment, performing procedures, teaching, and implementation of a care plan.dying care in the nursing interventions classification, a intervention" >nursing intervention defined as promotion of physical comfort and psychological peace in the final phase of life. See also dying.ear care in the nursing interventions classification, a intervention" >nursing intervention defined as prevention or minimization of threats to ear or hearing.embolus care: peripheral in the nursing interventions classification, a intervention" >nursing intervention defined as limitation of complications for a patient experiencing, or at risk for, occlusion of peripheral circulation. See also embolus.embolus care: pulmonary in the nursing interventions classification, a intervention" >nursing intervention defined as limitation of complications for a patient experiencing, or at risk for, occlusion of pulmonary circulation. See also embolus.emergency care in the nursing interventions classification, a intervention" >nursing intervention defined as providing life-saving measures in life-threatening situations. See also emergency.episodic care interventions aimed at patient cure or restoration to previous level of functioning.eye care in the nursing interventions classification, a intervention" >nursing intervention defined as the prevention or minimization of threats to eye or visual integrity.family-centered maternity care a pattern of caring for infants and their families used by Health and Welfare Canada. It is characterized by a great deal of flexibility and parental choice, and health care professionals are encouraged to individualize care. Breast feeding and rooming in are encouraged and grandparent and sibling visits are permitted.foot care see foot care.hair care in the nursing interventions classification, a intervention" >nursing intervention defined as the promotion of neat, clean, and attractive hair.health care see health care system.high-risk pregnancy care in the nursing interventions classification, a intervention" >nursing intervention defined as identification and management of a high-risk pregnancy to promote healthy outcomes for mother and baby.home health care see home health care.incision site care in the nursing interventions classification, a intervention" >nursing intervention defined as cleansing, monitoring, and promotion of healing in a wound that is closed with sutures, clips, or staples.indirect care services that are related to patient care but do not require interaction between the health care provider and the patient. Examples include charting and scheduling.infant care in the nursing interventions classification, a intervention" >nursing intervention defined as the provision of developmentally appropriate family-centered care to the child under one year of age.intensive care the care of seriously ill patients in a special hospital unit; see intensive care unit. Called also critical care.intrapartal care in the nursing interventions classification, a intervention" >nursing intervention defined as the monitoring and management of stages one and two of the birth process. See labor.intrapartal care: high-risk delivery in the nursing interventions classification, a intervention" >nursing intervention defined as assisting vaginal birth of multiple or malpositioned fetuses.kangaroo care in the nursing interventions classification, a intervention" >nursing intervention defined as promoting closeness between parent and physiologically stable preterm infant by preparing the parent and providing the environment for skin-to-skin contact.kinlein care kinlein.long-term care health care services required for an extended period of time by individuals unable to fully execute activities of daily living; it can be provided by a variety of agencies in outpatient settings as well as on an inpatient basis.managed care a method of health care delivery that focuses on collaboration among and coordination of all services to avoid overlap, duplication, and delays and to reduce costs. There is an emphasis on efficacy and timeliness of interventions to prevent unnecessary delays in discharge from the hospital or agency.medical/dental care in the omaha system, diagnosis and treatment by a physician or dentist.mouth care see mouth care" >mouth care.nail care in the nursing interventions classification, a intervention" >nursing intervention defined as promotion of clean, neat, attractive nails and prevention of skin lesions related to improper care of nails.newborn care in the nursing interventions classification, a intervention" >nursing intervention defined as management of the neonate during the transition to extrauterine life and the subsequent period of stabilization.nursing care in the omaha system, therapeutic activities in addition to intermittent service, including private duty nursing.ostomy care in the nursing interventions classification, a intervention" >nursing intervention defined as maintenance of elimination through a stoma and care of surrounding tissue. See also ostomy.ostomy care (omaha) in the omaha system, management of elimination through artificial openings, including colostomy and ileostomy.palliative care supportive care.perineal care in the nursing interventions classification, a intervention" >nursing intervention defined as maintenance of perianal skin integrity and relief of perineal discomfort.peripherally inserted central catheter care in the nursing interventions classification, a intervention" >nursing intervention defined as insertion and maintenance of a peripherally inserted central catheter.personal care the management of hygiene, including bathing, shampooing, shaving, nail trimming, dressing, and so on.point of care the location at which patient services are delivered.postanesthesia care in the nursing interventions classification, a intervention" >nursing intervention defined as monitoring and management of the patient who has recently undergone general or regional anesthesia.postmortem care in the nursing interventions classification, a intervention" >nursing intervention defined as providing physical care of the body of an expired patient and support for the family viewing the body.postoperative care see postoperative care.postpartal care in the nursing interventions classification, a intervention" >nursing intervention defined as monitoring and management of the patient who has recently given birth.pregnancy termination care in the nursing interventions classification, a intervention" >nursing intervention defined as the management of the physical and psychological needs of the woman undergoing a spontaneous or abortion" >elective abortion.prenatal care 1. care of the pregnant woman before delivery of the infant. See also pregnancy.2. in the nursing interventions classification, a nursing intervention defined as monitoring and management of the patient during pregnancy to prevent complications of pregnancy and promote a healthy outcome for both mother and infant.preoperative care see preoperative care.pressure ulcer care in the nursing interventions classification, a intervention" >nursing intervention defined as facilitation of healing in pressure ulcers" >pressure ulcers.preventive care the level of care in the health care system that consists of public health services and related programs such as school health education.primary care the routine outpatient care that a patient receives at first contact with the health care system.prosthesis care in the nursing interventions classification, a intervention" >nursing intervention defined as the care of a removable appliance worn by a patient and the prevention of complications associated with its use. See also prosthesis.respiratory care see respiratory care.respite care 1. services provided by a health care agency that permit a primary caregiver temporary relief from caring for an ill individual.2. in the nursing interventions classification, a intervention" >nursing intervention defined as the provision of short-term care to provide relief for a family caregiver.restorative care the level of care in the health care system that consists of follow-up care and rehabilitation to an optimal functional level.secondary care 1. treatment by specialists to whom a patient has been referred by primary care facilities; see also health care system.2. acute care.self care the performance of basic activities of daily living" >activities of daily living; see also under assistance and deficit.sickness/injury care in the omaha system, the appropriate responses to illness or accidents, including first aid, taking temperature, and seeking medical care.skilled nursing care the services provided by a registered nurse in a facility" >skilled nursing facility. It currently includes observation during periods of acute or unstable illness; administration of intravenous fluids, enteral feedings, and intravenous or intramuscular medications; short-term bowel and bladder retraining; and changing of sterile dressings.skin care activities and interventions designed to maintain integrity of integument, including care of pressure ulcers and massage.skin care: topical treatments in the nursing interventions classification, a intervention" >nursing intervention defined as the application of topical substances or manipulation of devices to promote skin integrity and minimize skin breakdown.spiritual care see spiritual care.subacute care comprehensive goal-oriented inpatient care designed for a patient who has had an acute illness, injury, or exacerbation of a disease process; it is rendered either immediately after or instead of acute care hospitalization, to treat specific active or complex medical conditions or to administer any necessary technically complex medical treatments in the context of the person's underlying long-term condition.supportive care interventions that help the patient achieve comfort but do not affect the course of a disease. Called also palliative care or treatment.tertiary care the level of care in the health care system that consists of complex procedures given in a health care center that has highly trained specialists and often advanced technology.total patient care a method of organizing care of patients such that one practitioner carries out all care requirements.traction/immobilization care in the nursing interventions classification, a intervention" >nursing intervention defined as management of a patient who has traction and/or a stabilizing device to immobilize and stabilize a body part.tube care in the nursing interventions classification, a intervention" >nursing intervention defined as management of a patient with an external drainage device exiting the body.tube care: chest in the nursing interventions classification, a intervention" >nursing intervention defined as management of a patient with an external water-seal drainage device exiting the chest cavity.tube care: gastrointestinal in the nursing interventions classification, a intervention" >nursing intervention defined as management of a patient with a gastrointestinal tube.tube care: umbilical line in the nursing interventions classification, a intervention" >nursing intervention defined as management of a newborn with an umbilical catheter.tube care: urinary in the nursing interventions classification, a intervention" >nursing intervention defined as management of a patient with urinary drainage equipment.tube care: ventriculostomy/lumbar drain in the nursing interventions classification, a intervention" >nursing intervention defined as management of a patient with an external cerebrospinal fluid drainage system. See also ventriculostomy and drain.urinary incontinence care in the nursing interventions classification, a intervention" >nursing intervention defined as assistance in promoting continence and maintaining perineal skin integrity. See also incontinence" >urinary incontinence.urinary incontinence care: enuresis in the nursing interventions classification, a intervention" >nursing intervention defined as promotion of urinary continence in children.urinary retention care in the nursing interventions classification, a intervention" >nursing intervention defined as assistance in relieving bladder distention. See also retention of urine.wound care in the nursing interventions classification, a intervention" >nursing intervention defined as prevention of wound complications and promotion of wound healing.wound care: closed drainage in the nursing interventions classification, a intervention" >nursing intervention defined as maintenance of a pressure drainage system at the wound site.managed carea contractual arrangement whereby a third-party payer (e.g., insurance company, government agency, or corporation) mediates between physicians and patients, negotiating fees for service and overseeing the types of treatment given.
See also: health maintenance organization. Managed care has largely replaced traditional medical indemnity insurance plans, under which payment is automatic and oversight procedures are minimal. Under managed care, the third-party payer controls specialty referrals, chiefly by appointing primary care physicians as "gatekeepers"; restricts the scope of covered services (particularly diagnostic procedures, choice of drugs prescribed, and length of hospital stay) for each diagnosis; and requires precertification review before hospital admission and a second opinion before elective surgery. Standards of care are regulated by practice guidelines, which may be set forth in oversimplified algorithms featuring binary (yes/no) choices. Prescribing alternatives are typically limited to drugs listed in the plan's formulary. Practice guidelines, formulary choices, and other policies affecting patient care incorporate contemporary medical knowledge and professional standards but also strongly reflect strategies for loss control and for the even distribution of actuarial risk among all beneficiaries. The plan may bargain with physicians, hospitals, diagnostic laboratories, and pharmacies for wholesale prices, or may compensate providers by capitation (that is, a flat annual fee based on the number of covered or potential patients) rather than by fees for services. Managed care organizations typically employ cost-containment measures such as emphasis on preventive medicine, audits of medical records, intensive review of claims, and punitive action against noncompliant providers. managed care (măn′ĭjd)n. Any arrangement for health care in which an organization, such as an HMO, another type of doctor-hospital network, or an insurance company, acts an intermediary between the person seeking care and the physician.managed care (1) The co-ordination of a constellation of health services, encompassing early intervention to control price, volume, delivery site and intensity of health services provided, to maximise the health of the insured, as well as the value of health benefits given.
(2) A philosophy in which the goal is a system that delivers quality, cost-effective healthcare by monitoring and recommending utilisation of services, as well as controlling the cost of those services.managed care Managed health care Health care A system that provides for the coordination of health services encompassing early intervention to control price, volume, delivery site, and intensity of health services provided, to maximize the health of the insured, and maximize the value of health benefits; a philosophy in which the goal is a system that delivers quality, cost effective health care by monitoring and recommending utilization of services, and controlling cost of services. See Managed care organization, Opt-out managed care. man·aged care (man'ăjd kār) An arrangement in the U.S. whereby a third-party payer (e.g., insurance company, government, or corporation) mediates between physicians and patients, negotiating fees for service and overseeing the types of treatment given. The third-party payer may mandate second opinions, precertification review for patients requiring hospital admission, negotiate wholesale prices with physicians, and implement cost-containment measures (e.g., hospital audits and claims reviews).
See: health maintenance organization
See also: capitationman·aged care (man'ăjd kār) Contractual arrangement whereby a third-party payer (e.g., insurance company) mediates between physicians and patients, negotiating fees for service and overseeing treatment. Managed Care
Managed CareA general term that refers to health plans that attempt to control the cost and quality of care by coordinating medical and other health-related services. The U.S. health care system has undergone major structural changes since the 1970s. The traditional way of obtaining medical care has been for a patient to choose a doctor and then pay that doctor for the services provided. This "fee-for-service" model, which has been financially rewarding for doctors, gives the patient the right to choose a physician. But the fee-for-service model underwent a rapid decline in the 1980s and 1990s as the concept of managed care took hold in the health care industry. Managed care is a new term for an old medical financing plan known as the HMO, or health maintenance organization. HMOs are not insured plans. They are prepaid health care systems, offering services to which the member is entitled, as opposed to a dollar amount guaranteed by an insurance policy. Doctors are paid a set amount of money monthly for each patient regardless of the level or frequency of care provided. HMOs emphasize preventive care. They became popular with employers who purchase health care coverage for their employees because they charged lower fees than insurance plans that reimburse patients for fee-for-service payments. Holding down the cost of medical care was one of the chief aims of HMOs. The first HMOs were started around 1930. The Kaiser Foundation Health Plan of California was one of the first and largest HMOs. Another large HMO is the Health Insurance Plan of Greater New York. Both Kaiser and Health Plan also have their own hospitals. The federal government has promoted HMOs since the 1970s, enacting the Health Maintenance Organization Act of 1973, 87 Stat. 931, and other legislation that allow HMOs to meet federal standards for Medicare and Medicaid eligibility. A person who participates in an HMO deals with a primary care physician, who directs the person's medical care and determines whether he or she should be referred for specialty care. This "gatekeeper" function has drawn both criticism and praise. Critics argue that a person can be tied down to a physician not of his or her choosing, who has complete control over whether the person will be seen by a specialist or be given special drugs or treatments. Critics also argue that HMO physicians are not allowed to perform thorough testing procedures because of the demands of HMO management to limit costs, and that this ultimately leads to rationing of medical treatment. Advocates of HMOs and managed care argue that it is an advantage to the patient to have one physician with full responsibility for his or her care. With few exceptions, these primary care physicians are trained as general practitioners, family practice physicians, pediatricians, internists, or obstetrician-gynecologists. The debate over National Health Care reform escalated during the first term of the Clinton administration. President bill clinton sought to overhaul the U.S. health care system by guaranteeing universal coverage while simultaneously controlling costs. His plan, which emphasized the managed care model, died in Congress, yet managed care continues to grow. Medicaid, the state-operated, but federally and state-funded, health care plans for the poor, started in 1966 as a fee-for-service program. By the 1990s, the conversion of Medicaid to a managed care model of service delivery had grown rapidly, serving as many as 10 million people. The early promise of HMOs has given way to deep concerns about the steady escalation of health care costs. By 2003, annual premium increases of almost 20 percent were hurting employers, employees, and small business owners who purchase their own health insurance. An average HMO family premium has risen from the $100–$150 range in 1993 to the $400–$600 range in 2003. HMOs defend the rise in costs by pointing to advances in medical technology that require the purchase of high-priced equipment, rising prescription drug prices, and a U.S. population that demands increasingly more services, in particular the aging "baby boomer" population. To manage costs and discourage frivolous visits, most HMOs now require members to make a co-payment for most types of medical visits. HMOs also point to state laws that undercut their management of costs by giving members the right to go outside of the HMO network of health providers for services. In addition, members can now take advantage of state laws that provide appeal rights when denied medical services. HMOs and health insurance companies have challenged these state laws, arguing that the 1974 federal Employee Retirement Income Security Act (ERISA) preempted these state laws. ERISA seeks to protect employee benefit programs, which include Pension plans and health care plans, through a lengthy set of standards, rules, and regulations. Health care providers have pointed to the comprehensive nature of ERISA as demonstrating the intent of Congress to maintain a uniform national system. However, the U.S. Supreme Court has been unsympathetic to these arguments. In Moran v. Rush Prudential HMO, Inc., 536 U.S. 355, 122 S. Ct. 2151, 153 L. Ed.2d 375 (2002), the U.S. Supreme Court, in a 5–4 decision, upheld an Illinois law that required HMOs to provide independent review of disputes between the primary care physician and the HMO. Debra Moran had complained of continued numbness, pain, and loss of function and mobility in her right shoulder. A nerve conduction test revealed that she had braxial plexopathy, which involves compression of the nerves. Moran researched this condition and found a doctor in Virginia who performed microsurgery to correct this type of problem. Because the doctor was "out-of-network," Rush Prudential refused to pay for Moran's consultation with him. The doctor diagnosed Moran as suffering from a syndrome that could be corrected with surgery. Moran gave her Illinois primary physician the diagnosis, which was confirmed by two Rush-affiliated thoracic surgeons. Moran was not satisfied with the surgical methods offered by these two doctors. Even though Rush denied her coverage, Moran elected to have the operation performed by the Virginia surgeon. The surgery was a success, but Moran faced medical bills of almost $95,000. She took advantage of the Illinois independent-review law. A year later, the judge determined, based on an independent medical examination, that the surgery performed by the Virginia doctor had been "medically necessary." This conclusion led Moran to ask the state court to order Rush to reimburse her for the medical costs of the surgery. The U.S. Supreme Court upheld the Illinois review law, finding that the law was an insurance regulation rather than a benefit regulation. Therefore, ERISA did not preempt the state regulation. HMOs suffered an even greater defeat in their quest to manage services and costs when the U.S. Supreme Court upheld "any willing provider" laws passed by Kentucky. The laws permitted HMO members to obtain medical services from outside the designated list of HMO providers. HMOS again objected, contending that ERISA preempted the laws because they clearly dealt with health care benefits. The Court, in Kentucky Association of Health Plans, Inc. v. Miller, 538 U.S. 329, 123 S. Ct. 1471, 155 L. Ed.2d 468 (2003), unanimously rejected this argument. It again characterized the laws as insurance regulations, which are exempt from ERISA Preemption. Further readings Hertel, James. 2002. "Health Care Woes: Two Views." Rocky Mountain News (March 2). Lee, Bryan. 2003. "Managed Care: Health Providers' Bill of Rights Now Law in California." Journal of Law, Medicine & Ethics 31 (spring).Orentlich, David. 2003. "The Rise and Fall of Managed Care: A Predictable 'Tragic Choices' Phenomenon." Saint Louis University Law Journal 47 (spring). Cross-references Health Care Law; Health Insurance; Physicians and Surgeons. |