Managed care. Shifts health care from an altruistic model to a business framework.

The term managed care, as used throughout the scientific and lay literature, has become a generic label without a clear, universally accepted definition. The many definitions and descriptions of managed care are usually directly related to the model under discussion. Nevertheless, as nurse educators attempt to align curricula with the evolving health care environment, it is imperative that students gain an understanding of the concept of managed care and the skills needed to practice in the managed care environment. Schools of nursing must prepare students to deal with the consequences of managed care, namely, the changing base of power, conflicts, and ethical dilemmas across settings. * The drive to control health care costs in the 1990s brought about unprecedented change for nurses. Regardless of the strategies implemented in the name of managing care, the evolving health care environment has changed where and how nurses practice. To aid faculty in the revision of the nursing curriculum, an attempt was made to arrive at an empirically based definition of managed care that will provide a conceptual foundation for future research and theoretical discussions. Other goals were to identify consequences of managed care across disciplines and models implemented in the name of managing care, and to identify skills needed by nurses today. Data Collection Using Rodgers' (1) evolutionary method of concept analysis, data were collected through a three-phase process: 1) a systematic review of multidisciplinary literature related to managed care, 2) interviews with managers/administrators, and 3) observation of case managers practicing in managed care environments. The analysis emphasized the evolutionary component of the concept of managed care, providing a historical context and identifying attributes and characteristics. Further, the analysis focused on the consequences of managed care and its impact on nursing education and practice. Using a qualitative process, reliability and validity issues were dealt with in terms of the "trustworthiness" of the data analysis and interpretation (2). In other words, the focus was on the accuracy and adequacy of the match between the empirical categories, such as the consequences of managed care, and the realities of the study samples. Three strategies were incorporated to ensure trustworthiness: 1) triangulation of methods (collecting data from multiple sources, such as reviewing the literature, interviewing managers, and observing case managers); 2) triangulation of sources (literature from multiple disciplines and interviews with managers from varied settings and backgrounds); and 3) member checks (validating findings and interpretations through comparison with the literature and asking representative subjects to verify the accuracy and adequacy of the data synthesis). Definition of Managed Care This definition is based on the predominant attributes and characteristics of the concept synthesized from the data: "Managed care is a business framework for organizing the delivery of health care services while controlling service and resource utilization through incentives to control costs and decision making based on business parameters. Managed care is most commonly operationalized through a process referred to as "case management." Synthesis of the data from all three phases of data collection resulted in these predominant attributes of managed care: business framework, organizing the delivery of health care services, controlling service and resource utilization, incentives to control costs, and decision making based on business parameters. Table 1 identifies the defining characteristics of each attribute. Table 1. Predominant Attributes and Defining Characteristics of Managed Care ATTRIBUTE DEFINING CHARACTERISTICS Business framework * Discounted or capitated contracts * Preauthorization for care * Prospective, concurrent, or retrospective reviews Organizing delivery of health * Integrated health care systems care services * Managed care organizations Health Maintenance Preferred Provider Point of Service Controlling service and * Standardizing practice patterns resource utilization * Gatekeepers Incentives to control costs * Provider/consumer assuming part of financial risk of care * Limiting provider and consumer choices Decision making based on * Allocation or denial of service business parameters decisions made by non-health care providers (third-party payers) * Shift from altruistic health care model to business framework Consequences of Managed Care While nursing has traditionally been built on an altruistic philosophy that values caring and a patient-centered focus of care, the implementation of the concept of managed care has shifted health care to a business framework. …