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MANAGED HEALTH CARE Many people use the term "managed health care," but with recent changes in HMOs and other health plans it can be hard to pin down exactly what it means.  In general, "managed health care" can mean any organizational processes that improve health care quality or reduce health care cost or any organization that uses such processes. In common usage during the 1980's and 1990's, "managed health care" referred to HMOs, PPOs, and POS plans. However, many of these plans are now lifting constraints on access to specialists and providing some coverage for services by out-of-network providers.  On the other end of the spectrum, many fee-for-service plans are adopting some methods to contain costs and guarantee suitable patient care that have been traditionally associated with managed health care.  As a result, the distinctions between these plan labels have blurred and they have become less useful as a way to define managed health care. A second way to define "managed health care" is by specific attributes of a plan. managed health care plans are generally characterized by: provision of a comprehensive set of health care services for a monthly premium; a network of providers with whom the plan has contractual arrangements for payment and delivery of care; practice quality and efficiency standards for selection of providers in the network; limited coverage for services provided by providers outside the network; incentives for providers to discourage use of those services with little health benefit; programs for quality assurance and utilization review; practice guidelines to improve outcomes and reduce costs; pre-admission certification from the plan before coverage for a hospital stay; and second surgical opinion before coverage for surgery. Some managed health care plans may let you choose a specialist as your primary care physician, particularly if you have a chronic health condition related to that specialty.  If you have high blood pressure, heart disease or diabetes, you may wish to select an internist who specializes in these conditions. Your Primary Care Provider (PCP) often coordinates your care, sees you when you are sick, and makes decisions about whether you should see a specialist. Even managed health care plans with a network of providers generally provide coverage for care provided by non-network providers in the case of a true emergency.  Most plans require you to let them know of an emergency hospital admission within a certain period of time after admission. Check how your health plan defines a emergency.  Sometimes there is another level of care called "Urgent Care" that is not a true medical emergency, but does require quick medical attention.  Does your plan provide urgent care services after hours?  Some plans are moving toward same-day appointments that can address urgent care problems during regular hours. "Pre-certification" or ""Pre-authorization" means that you must get authorization from your insurer to be covered for a hospital admission or other service (such as surgery) unless it is a medical emergency.  When this is required for a hospital admission, to determine whether the problem requires a hospital admission or could be done on an outpatient basis, this requirement is called "Pre-admission Certification."  "Second Surgical Opinion" is a process whereby patients must get the medical opinion of a second doctor before a surgery is covered by an insurance plan. "Utilization Review" is the process of evaluating whether medical and surgical services are appropriate, medically necessary and high quality.  It covers the appropriateness of hospital admission, hospital services provided during a hospital stay, the length of a stay, and discharge practices. "Concurrent Review" is review of hospital services during a hospital stay to ensure appropriate services and proper placement upon discharge. "Retrospective Review" is review of medical services after they occur to ensure that they were necessary and appropriate. Increasingly in public usage, the term "managed health care" has taken on a colloquial meaning that focuses more on cost reduction than its original meaning.  In the political arena, "managed health care" has become a target for people who are opposed to constraints on care through providers.  People often talk about a trade-off between choice and cost associated with managed health care.  In theory, this trade-off need not be bad if consumers get a large reduction what they pay for premiums (or a corresponding increase in salaries and wages) in return for a little reduction in choice.  However, this issue heats up when employers do act in the best interest of their employees or when people do not realize their choice limitations when they sign up for a "managed health care" plan. MANAGED HEALTH CARE