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D W Garnick

Publications and source records attributed to D W Garnick.

At least 19 recordsLinked to original sources
PubMed2000

Why carve out? Determinants of behavioral health contracting choice among large U.S. employers.

Many U.S. employers have carved substance abuse and mental health services out of their medical plans, changing the way millions of people access care. Employers that take this approach contract directly with specialized vendors, bypassing their general health plans. Since carving out may alter access and treatment, there is a need to understand why employers take this approach. This article reviews various hypotheses about why purchasers carve out and tests them using data from a survey of America's largest employers, the Fortune 500 firms. Size is the strongest predictor of an employer's decision to carve out behavioral health once other characteristics are controlled for. Employers that report they value coordination are less likely to carve out, while those that value special expertise are more likely to carve out. Employers are less likely to carve out enrollees in health maintenance organizations (HMOs) than those in other types of plans.

Employer Health Costs↗
PubMed2000

Adverse selection and price sensitivity when low-income people have subsidies to purchase health insurance in the private market.

Policymakers interested in subsidizing low-income people's purchase of private insurance face two major questions: will such subsidies lead to adverse selection, and how large do the subsidies have to be to induce large numbers of eligible people to purchase the insurance? This study examines New Jersey's short-lived experience with a premium subsidy program, Health Access New Jersey (Access Program). The program was for people in families with incomes below 250% of the poverty level who were not eligible for health insurance provided by an employer, or Medicaid or Medicare, and who wished to purchase policies in the state's individual health insurance market, the Individual Health Coverage Program. Surveying a random sample of Access Program policyholders, we compared their demographic and socioeconomic characteristics, as well as their health status, to those of other New Jersey residents who had family incomes below 250% of the poverty level to determine whether there was any evidence of adverse selection among the people who enrolled in the Access Program. The people who enrolled were not in worse health than uninsured people with incomes below 250% of the poverty level, but they were quite price sensitive. Most enrollees had incomes within the low end of the income eligibility distribution, reflecting the structure of rapidly declining subsidies as income increased.

Adult↗
PubMed1999

Use of performance standards in behavioral health carve-out contracts among Fortune 500 firms.

OBJECTIVE: To determine the prevalence and nature of performance standards in specialty managed behavioral healthcare contracts among Fortune 500 companies. STUDY DESIGN: This was a cross-sectional survey of all companies listed on the Fortune 500 during 1994, 1995, or both. METHODS: From April 1997 to May 1998 we conducted a mailed survey with phone follow-up. Of the 68% of firms that responded, over one third reported carve-out contracts. The survey focused on whether companies had behavioral health carve-out contracts with specialty vendors and characteristics of these contracts, including the use of performance standards. RESULTS: More than three quarters of the Fortune 500 companies reporting specialty behavioral healthcare contracts used at least one performance standard. Most common were administrative standards (70.2%) and customer service standards (69.4%). About half of the companies used quality standards, whereas only a third used provider-related standards. Most (58.8%) companies using performance standards also specified financial consequences. Larger Fortune 500 firms were significantly more likely to use performance standards. Risk contracts and contracts that included all covered employees were also more likely to include some categories of standards. CONCLUSIONS: Administrative and customer service standards may be most common because companies find it easier to specify those standards, especially compared with clinical quality measures. To the extent that employers want to obtain the most value from their behavioral healthcare purchasing, we expect that more will begin to adopt quality standards in their contracts, especially as performance measures become more refined. Reliance on accreditation, however, is an alternative approach for employers.

Behavioral Medicine↗
PubMed1999

Can adverse selection be avoided in a market for individual health insurance?

Adverse selection is a potentially significant problem in the individual (nongroup) health insurance markets if states use regulations to restrict insurance companies' ability to select whom they will insure. In 1993, New Jersey implemented the Individual Health Coverage Program (IHCP), presenting an opportunity to test for adverse selection when insurers' ability to select enrollees is severely restricted. The authors collected socioeconomic, demographic, and health status data from a sample of 2,211 adults covered by IHCP policies and compared the IHCP enrollee characteristics with those of two control groups of New Jersey residents (uninsured adults and adults with employer group insurance). Adverse selection does not appear to have occurred against the IHCP. However, the IHCP premiums were not cheap, and the findings suggest that people who can afford to purchase individual insurance and do so are, on average, healthier than those who do not choose to enroll, probably because the latter cannot afford insurance.

Adult↗
PubMed1999

Meeting information needs: lessons learned from New Jersey's Individual Health Insurance Reform Program.

At national and state levels, there have been significant changes in the regulations governing individual and small group health insurance markets. Reforms to the individual health insurance market in New Jersey exemplify the challenges of informing consumers about changes in the regulation of insurers, where the changes are intended to simplify and broaden access to health insurance. To best take advantage of expanded access to coverage under new regulations governing the individual health insurance market, individuals need to understand the changed rules under which carriers determine eligibility and premiums. Survey results from New Jersey indicate, however, that a significant proportion of people who purchased policies under the restructured individual health insurance market did not fully understand how the new market operates.

Adult↗
PubMed1997

Make or buy: HMOs' contracting arrangements for mental health care.

Many health maintenance organizations (HMOs) are contracting with external vendors for mental health care, rather than maintaining an internal mental health department. We develop a framework for analyzing HMOs' contracting choices, rooted in transaction cost economics. Applying this framework, external contracting seems most likely to appeal to smaller, newer HMOs and those located in areas with multiple vendors. Pressure from value-oriented buyers may make it harder for HMOs to provide mental health internally, without costly reforms to their product. HMO contracting arrangements deserve further study, given their implications for cost and the quality of care.

Contract Services↗
PubMed1996

Private sector coverage of people with dual diagnoses.

In general, people with dual diagnoses account for a significant proportion of both the mental health and substance abuse populations. Most published information on dual diagnosis comes from research on selected treatment programs that are largely funded from public sources. This analysis uses private health insurance claims and eligibility files for 1989 to 1991 for three large firms to identify individuals with both substance abuse and mental health claims and to examine their characteristics, charges, and utilization. More than half of people with dual diagnoses incurred significant charges over three years in both mental health and substance abuse. These individuals with high mental health charges were more likely to be male than were patients with mental health claims alone; they were less likely to be male than were patients with claims for substance abuse and no mental health services. They were also significantly younger than were patients with substance abuse or mental health utilization only for two of the firms. The average charges for people with dual diagnoses were higher than those for patients with substance abuse or mental health claims only.

Adult↗
PubMed1996

Physician profiling in group practices.

Profiling is a technique that large, multispecialty group practices, like many insurers, can use to monitor and improve quality and efficiency. Groups can examine physician performance by calculating ratios of medical inputs to patient or population outputs. Physician control can help to achieve balance between clinical benefits and economic considerations. Profiles need to reflect a group's multiple missions, such as clinical care, research, and education; philosophy of care; and organizational ethos regarding physician compensation systems. Groups may need to customize standard approaches because of their emphasis on early utilization of specialists and the atypical case mixes often found in referral practices.

Group Practice↗
PubMed1996

Profiling resource use by primary-care practices: managed Medicare implications.

Variations in elderly Medicare beneficiaries' health service use are examined using a 100-percent sample of fee-for-service (FFS) claims data from Alabama, Iowa, and Maryland. Provider specialty, group practice type, practice size, and location are found to be significant factors affecting hospital and ambulatory care utilization and cost, after controlling for patient and regional characteristics. These results provide insights into utilization and cost expectations from different types of primary-care gatekeepers as the Medicare managed care market develops.

Aged↗
PubMed1995

Variation in office-based quality. A claims-based profile of care provided to Medicare patients with diabetes.

OBJECTIVES: To demonstrate that claims data "profiling" can be used as an ongoing method to support ambulatory care quality improvement; to measure the quality of office-based care provided to elderly patients with diabetes in three states; and to identify factors associated with better attainment of quality standards. STUDY DESIGN: A cross-sectional study based on a 100% sample of the Medicare claims (Part B and Part A) submitted between July 1, 1990, and June 30, 1991. SETTING: All primary care practices (both solo and group) actively seeing Medicare patients with diabetes in Alabama, Iowa, and Maryland (n = 2980). PATIENTS: All elderly (> or = 65 years) Medicare patients seen by the study physicians and assigned a diagnosis of diabetes (n = 97,388) by any office-based physician during the year. MAIN OUTCOME MEASURES: The proportion of patients with diabetes receiving the following procedures (from any provider) at least once during the study period: hemoglobin A1C measurement, ophthalmologic examination, total cholesterol measurement, and blood glucose measurement. We considered the first three services to be optimally recommended and blood glucose measurement to be of limited use. RESULTS: Based on analyses of services provided in the ambulatory setting, we found that 84% of diabetics did not appear to receive the recommended hemoglobin A1C measurement, 54% did not see an ophthalmologist, and 45% received no cholesterol screening. Practice patterns varied considerably across the three states (up to 2.38-fold), even after adjusting for patient case mix and physician characteristics. Patients of general practitioners were less likely to meet recommended quality criteria than patients of internists or family practitioners. Patients receiving care from rural practitioners were less likely to receive services, either recommended or not, than those in urban locations. CONCLUSIONS: Elderly patients with diabetes do not appear to be receiving optimal care. This study underscores the value of practice guideline development and dissemination in the ambulatory arena. This study provides substantial evidence that existing administrative claims data can be used to support ambulatory quality improvement activities.

Aged↗
PubMed1995

Designing and using measures of quality based on physician office records.

This article presents our principles for developing performance measures to assess the quality of ambulatory care. The measures were developed as part of a project for developing and evaluating methods to promote ambulatory care quality (DEMPAQ). We describe our design for the performance measures, present examples of the DEMPAQ review criteria, and show the formats we used to feed back information to physicians. We conclude by presenting the results of our appraisal of the performance measures showing how evaluation can aid in the interpretation of measurement findings.

Ambulatory Care↗
PubMed1995

Developing a quality improvement database using health insurance data: a guided tour with application to Medicare's National Claims History file.

Health policy researchers are increasingly turning to insurance claims to provide timely information on cost, utilization, and quality trends in health care markets. This research offers an in-depth description of how to systematically transform raw inpatient and ambulatory claims data into useful information for health care management and research using the Health Care Financing Administration's National Claims History file as an example. The topics covered include: (a) understanding the contents and architecture of claims data, (b) creating analytic files from raw claims, (c) technical innovations for health policy studies, (d) assessing data accuracy, (d) the costs of using claims data, and (e) ensuring confidentiality. In summary, claims data are found to have great potential for quality of care analysis. As in any analysis, careful development of a database is required for scientific research. The methods outlined in this study offer health data novices as well as experienced analysts a series of strategies to maximize the value of claims data for health policy analysis.

Aged↗
PubMed1995

Agreement between physicians' office records and Medicare Part B claims data.

This article tests agreement between demographic, diagnostic, and procedural information from primary-care physicians' office records and Medicare Part B claims for Maryland Medicare beneficiaries. The extent of agreement depended on the category of information being compared. Demographics matched poorly, probably due to incomplete record samples. Important diagnoses were often missing from the medical record. When claims indicated presence of disease, the patient was likely to have the disease, but claims did not capture all people who have the disease. Additionally, many laboratory tests and procedures were missing from the primary-care record. The appropriate use of either of these data sources depends on the specific research question that is being asked.

Demography↗
PubMed1995

Measuring hospital mortality rates: are 30-day data enough? Ischemic Heart Disease Patient Outcomes Research Team.

OBJECTIVE: We compare 30-day and 180-day postadmission hospital mortality rates for all Medicare patients and those in three categories of cardiac care: coronary artery bypass graft surgery, acute myocardial infarction, and congestive heart failure. DATA SOURCES/COLLECTION: Health Care Financing Administration (HCFA) hospital mortality data for FY 1989. STUDY DESIGN: Using hospital level public use files of actual and predicted mortality at 30 and 180 days, we constructed residual mortality measures for each hospital. We ranked hospitals and used receiver operating characteristic (ROC) curves to compare 0-30, 31-180, and 0-180-day postadmission mortality. PRINCIPAL FINDINGS: For the admissions we studied, we found a broad range of hospital performance when we ranked hospitals using the 30-day data; some hospitals had much lower than predicted 30-day mortality rates, while others had much higher than predicted mortality rates. Data from the time period 31-180 days postadmission yield results that corroborate the 0-30 day postadmission data. Moreover, we found evidence that hospital performance on one condition is related to performance on the other conditions, but that the correlation is much weaker in the 31-180-day interval than in the 0-30-day period. Using ROC curves, we found that the 30-day data discriminated the top and bottom fifths of the 180-day data extremely well, especially for AMI outcomes. CONCLUSIONS: Using data on cumulative hospital mortality from 180 days postadmission does not yield a different perspective from using data from 30 days postadmission for the conditions we studied.

Cardiology Service, Hospital↗
PubMed1994

A computerized system for reviewing medical records from physicians' offices.

BACKGROUND: Review of clinical performance in office-based care is increasing in importance as more medical care shifts to outpatient settings. Decisions made in primary care settings can save lives and limit disability through prevention and early intervention in disease. Information is needed to assess quality of care by answering such questions as whether drugs are prescribed and monitored appropriately, follow-up on serious health threats is carried out promptly, or procedures are performed for appropriate indications. Moreover, data from medical records are essential to provide important clinical information not found in the more widely used administrative data sets. Managed care organizations, too, face the need to respond to requests for objective information about the quality of primary care that they provide. Those organizations now planning assessments of primary care will need to consider the cost of obtaining information from medical record review. METHODS: The DEMPAQ Record Review System (DRRS) is a tool for peer review organizations (PROs) to use to review ambulatory care given to Medicare beneficiaries in physicians' offices. The system is described in terms of functions (activities commonly performed in the course of an office visit, such as drug prescribing), indicators (summary measures of quality for each key function of clinical care), and clinical items (for example, specific drugs or tests for each function and indicator)--a total of 263 indicators in all. A framework is provided for measuring the operational costs of a review system based on medical records. RESULTS: The costs directly associated with a fully operational review system were less than $48 per case in Iowa and Alabama and $72 per case in Maryland. On average, reviewers spent about an hour per case signed on to DRRS; average review times declined over time with practice. About half the cost of the review process is accounted for by administrative costs. Therefore, once the effort has been made to obtain records, the additional cost of abstracting more data items is relatively low. Since samples of 300-500 records suffice to measure average performance for a region or state, costs per region/state approximate $15,000 to $25,000 per measurement cycle for assessment of a wide array of clinical areas. SUMMARY: The cost of collecting information on quality of care from medical records using the review system falls within current budgets for PRO review. However, organizations planning to implement a quality improvement campaign should also consider the costs of analyzing the data, reporting information to physicians, and continuing to monitor changes in performance.

Aged↗