Document: Managed Care
Classification: Position Paper
Date: May 1995
Status: Approved by the ASCLS House of Delegates July, 1995
As health care costs continue to escalate, with $1 trillion and 14 percent of the United States gross domestic product spent on health care in 1994, elected officials for all levels of government attempt to develop economic strategies to address the issues of cost and access to cost-effective quality health care. Regardless of proposed government interventions, the health care market is moving towards managed care. Managed care is the method of financing health care which is most likely to control costs while maintaining quality. Predictions indicate that within this decade, managed care will account for more than 80 percent of U.S. private health insurance coverage.
Under a fee for service arrangement, consumers choose their own physicians and health care providers, follow the recommended treatment, and pay the fees determined by the providers. If the consumer has health insurance, the fees for medical service rendered are partially or fully covered by the insurance policy, which is customarily funded by the consumer's employer. Under this arrangement, consumers, insurance companies, and employees have minimal influence over the fee charged, the appropriateness or quality of care delivered.
Managed care systems address cost, access and quality demands through health care systems that encompass both the financing and delivery of health care services to subscribers. Cost is customarily addressed through a capitated fee structure and the implementation of practice parameters. Formal programs for ongoing quality assurance and utilization review are essential components of managed care programs.
The goal of managed care is to control costs while maintaining quality. Providers usually receive compensation as a fixed amount per program member. Similarly, members and/or their employers, pay a fixed monthly amount to the plan, yet pay nothing or a nominal amount for each encounter. Mechanisms to assure the efficiency and appropriateness of care include: initial consultation with a primary care physician who determines which specialist, if any, needs to be consulted; early intervention in health care as a means to decrease downstream costs; utilization review to determine the quality and appropriateness of the care delivered to its members.
Since clinical laboratory testing is an integral part of the delivery of health care and the clinical laboratory scientist, prepared at the baccalaureate degree level, has the expertise in analytical, diagnostic and therapeutic testing, this expertise must be included in the development of practice parameters.
As patient advocates, the clinical laboratory scientists provide an integral role in achieving greater economies in the delivery of health care.
Through standardized techniques, such as clinical decision analysis, clinical laboratory scientists may order initial and/or reflexive testing for consumers and revise inappropriately ordered tests resulting in appropriate and cost-effective clinical laboratory testing.
Clinical laboratory scientists have the unique ability to enhance effective utilization of clinical laboratory services by providing feedback to physicians on utilization patterns, test ordering, cost effectiveness and identification of the clinical impact of irrelevant or obsolete tests. ASCLS affirms the ethical responsibility of clinical laboratory scientists to educate physicians and consumers about the clinical relevance of clinical laboratory tests.
ASCLS affirms the role of regulation in assuring standards in the provision of medical care. Given the financial incentive for managed care organizations to fail to provide necessary services and to encourage disenrollment of costly consumers, regulatory standards are needed in order to protect the public.