Term Paper on Community Managed Health Care system and the rationale for establishment of community clinics

In a community-based health care system, every possible treatment cannot be provided to everyone — any more than everyone can have everything in a tax-based or private insurance system. But there are criteria for determining what will be restricted, and how. In Germany, these principles are laid out in law: a service must be necessary in order to be covered by the statutory health insurance system. This criterion builds on the individual-patient perspective: patients have a right to care that is objectively necessary to cure their disease, prevent a disease from progressing, or ease their suffering. But the perspective of the community is also considered: the costs must be reasonable in relation to the potential benefit.


Development of Systems of Care for Health Services
In 1969, the Joint Commission on Health found that individuals with SMI were typically underserved, or were served inappropriately in excessively restrictive settings such as residential facilities and psychiatric hospitals. Numerous subsequent reports have substantiated these findings.
 
Managed Care and Health Services
During the same decade in which the system-of-care philosophy was embraced, managed health care arrangements were widely adopted. Initially, the use of managed care to finance and deliver health and substance-abuse services—also referred to as behavioral health services—occurred primarily within private, employer sponsored health plans. In recent years, however, managed care arrangements for behavioral health services have been implemented more widely in the public sector, particularly in state Medicaid programs. With the advent of managed care, many questions have been raised about the implications for delivering health services. Of particular concern is whether progress in building systems of care is in jeopardy, whether the system-of-care philosophy will be abandoned, whether the use of Medicaid to support system-of-care components will be curtailed, and whether access to appropriate, comprehensive, high-quality behavioral health services will be compromised.


Without effective risk-adjustment strategies to protect the financial interests of managed care organizations(MCOs) and providers, there is little incentive in a managed care system to serve the “high utilizers” of services—those who are the most expensive to serve. For individuals with the most serious and complex problems, under service within the managed behavioral health care system, there would be a likely result of shifting the responsibility for providing and funding their care to other systems such as those we are currently seeing in criminal justice and incarceration of the ly ill. The loss of an interagency focus is another concern. Interagency planning at the systemic level and interagency service planning are both integral aspects of systems of care. Both of these elements could be lost if they are not directly incorporated into managed care plans, requests for proposals, and contract requirements for MCOs. Many of the private, for-profit MCOs that are increasingly managing Medicaid behavioral health services have limited experience with interagency systems of care. Concerns about providers have been raised; particularly that smaller programs and nontraditional programs and providers might be eliminated from provider networks and no longer be available.

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