A general term which refers to a system of health care delivery that tries to manage the costs of health care, the quality of that health care, and access to that care. Common elements include a restricted group of contracted providers, some limitations on benefits to subscribers who use non-contracted providers (unless authorized to do so), and some type of authorization system. Managed care is actually a spectrum of systems, ranging from so-called managed indemnity, through PPOs, Point of Service, open panel HMOs and closed panel HMOs.
A system that uses financial incentives and management controls to direct patients to providers who are responsible for giving appropriate care in cost-effective treatment settings. Such systems are created to control the cost of health care.
A system for providing health care delivery that may include set payment to doctors, financial incentives for consumers to use certain doctors, and coordination of health care services. There are different types of managed care systems. The most common are Health Maintenance Organizations (HMOs) and preferred Provider Organizations (PPOs). Generally, HMO members must sign up with a medical group and see doctors within that group. Some plans may allow members to see doctors "out-of-plan" at increased cost to the member. In most HMOs, the member chooses a "Primary care Provider" who becomes the doctor primarily responsible for the members care. The primary Care Provider may refer the member to specialists, if necessary. In PPOs, the member will pay less to see doctors in the plan and will pay more to see doctors out of the PPO. In PPOs, and in some HMOs, your ability to get care may be controlled by a "utilization review committee", a group that decides if health care services are necessary and are covered under the plan.