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PubMed2003

A randomized trial of an acid-peptic disease management program in a managed care environment.

OBJECTIVE: To study the effectiveness of a disease management program for patients with acid-related disorders. STUDY DESIGN: A cluster-randomized clinical trial of 406 patients comparing a disease management program with "usual practice." PATIENTS AND METHODS: Enrolled patients included those presenting with new dyspepsia and chronic users of antisecretory drugs in 8 geographically separate physician offices associated with the Orlando Health Care Group. There were 35 providers in the intervention group and 48 in the control group. The disease management program included evidence-based practice guidelines implemented by using physician champions, academic detailing, and multidisciplinary teams. Processes of care, patient symptoms, quality of life, costs, and work days lost were measured 6 months after patient enrollment. RESULTS: Compared with usual practice, disease management was associated with improvements in Helicobacter pylori testing (61% vs 9%; P = .001), use of recommended H pylori treatment regimens (96% vs 10%; P = .001), and discontinuation rates of proton pump therapy after treatment (70% vs 36%; P = .04). There were few differences in patient quality of life or symptoms between the 2 study groups. Disease management resulted in fewer days of antisecretory therapy (71.7 vs 88.1 days; P = .02) but no difference in total costs. CONCLUSION: This disease management program for patients with acid-related disorders led to improved processes of care. The effectiveness of such a program in other settings requires further study.

Adult↗
PubMed2002

Evaluation of a faculty development program in managing care.

PURPOSE: To evaluate a faculty development program that teaches quality improvement and cost-effectiveness. METHOD: From October 2000 to February 2001, a two-part faculty development program was offered to 39 physicians from 19 U.S. medical schools supported by grants from the Partnerships for Quality Education (PQE) and Undergraduate Medical Education in the 21st Century (UME-21). Special features of the program included partnerships between academic and community physicians from each school, development of an educational innovation of interest to the participants, concurrent development of teaching skills and new medical knowledge, learning leadership skills (e.g., how to train colleagues to teach), and practice periods. The program focused on quality improvement and cost-effectiveness, but included other "managing care" topics. Prior to and after the course, participants assessed their knowledge of and competence to teach these topics, as well as other managing care topics. They also assessed their competence as medical educators and leaders. After the course, they indicated their progress in implementing their proposed educational innovations. RESULTS: Thirty-two of the 39 physicians completed evaluations both before and after the program. Self-assessed knowledge and competence to teach quality improvement and cost-effectiveness were significantly higher at the end of the course, as were all self-assessed teaching and leadership skills. The largest change scores occurred in assessments of competency to teach the new topics and to teach in new ways. Participants who implemented their innovations rated their competencies to teach quality improvement and cost-effectiveness higher than did non-implementers. CONCLUSION: Opportunities for faculty to learn how to teach a topic of stated importance to them, to practice what they have learned, and to work collaboratively with partners improved teaching skills.

Academic Medical Centers↗
PubMed2003

High-risk patients identified before costs explode.

Some health plan members exhibit subtle signs that they are at high risk of incurring major medical costs months before they actually begin running up big bills. If these ticking time bombs can be identified, they can be brought into care management programs before their costs explode.

Cost Control↗
PubMed2005

Cost-effectiveness of improving primary care treatment of late-life depression.

CONTEXT: Depression is a leading cause of functional impairment in elderly individuals and is associated with high medical costs, but there are large gaps in quality of treatment in primary care. OBJECTIVE: To determine the incremental cost-effectiveness of the Improving Mood Promoting Access to Collaborative Treatment (IMPACT) collaborative care management program for late-life depression. DESIGN: Randomized controlled trial with recruitment from July 1999 to August 2001. SETTING: Eighteen primary care clinics from 8 health care organizations in 5 states. PARTICIPANTS: A total of 1801 patients 60 years or older with major depression (17%), dysthymic disorder (30%), or both (53%). INTERVENTION: Patients were randomly assigned to the IMPACT intervention (n = 906) or to usual primary care (n = 895). Intervention patients were provided access to a depression care manager supervised by a psychiatrist and primary care physician. Depression care managers offered education, support of antidepressant medications prescribed in primary care, and problem-solving treatment in primary care (a brief psychotherapy). MAIN OUTCOME MEASURES: Total outpatient costs, depression-free days, and quality-adjusted life-years. RESULTS: Relative to usual care, intervention patients experienced 107 (95% confidence interval [CI], 86 to 128) more depression-free days over 24 months. Total outpatient costs were USD $295 (95% CI, -$525 to $1115) higher during this period. The incremental outpatient cost per depression-free day was USD $2.76 (95% CI, -$4.95 to $10.47) and incremental outpatient costs per quality-adjusted life-year ranged from USD $2519 (95% CI, -$4517 to $9554) to USD $5037 (95% CI, -$9034 to $19 108). Results of a bootstrap analysis suggested a 25% probability that the IMPACT intervention was "dominant" (ie, lower costs and greater effectiveness). CONCLUSIONS: The IMPACT intervention is a high-value investment for older adults; it is associated with high clinical benefits at a low increment in health care costs.

Age Factors↗
PubMed1998

Impact of a Medicaid primary care provider and preventive care on pediatric hospitalization.

OBJECTIVE: This study evaluates the impact that a Medicaid managed care program had on avoidable hospitalization, a form of health care misuse that we hypothesize can be reduced by improved access to and quality of primary care in the context of a managed care program. Ambulatory care sensitive (ACS) hospitalizations, a previously defined categorization of hospitalization, as well as all pediatric hospitalizations were also studied. INTERVENTION: The Maryland Access to Care (MAC) was a fee-for-service, gatekeeper, Medicaid managed care program with assigned primary medical providers and required Early Periodic Screening, Diagnosis, and Treatment (EPSDT) examinations. Medicaid managed care elements include: 1) assignment to primary medical provider (PMP) either by voluntary choice or mandatory enrollment of eligible Aid to Families With Dependent Children (AFDC), Medical Assistance (medical needy), and Supplemental Security Income; 2) a medical home accessible 24 hours a day, 7 days a week; 2) PMP must authorize emergency department (ED), inpatient, and specialty care but there were no disincentives to PMP for referral; 3) fee-for-services reimbursement (with a physician rate increase) for primary care, authorized specialist care, and hospitalization; and 4) an on-line eligibility verification system was available to all medical providers. Pre-enrollment as well as publicity allowed MAC to be phased in rapidly, resulting in 70% to 80% enrollment by the end of the first program year. DESIGN: The design of this study is that of a pre- and postevaluation of the MAC program using Medicaid claims analysis of data 3 years pre-MAC and 2 years post-MAC. In multivariate analyses, this study also compares MAC-enrolled children to non-MAC-enrolled children (before and after MAC began) to estimate the impact of MAC enrollment while controlling for potential confounders. SETTING: State of Maryland from 1989 to 1993. PATIENTS: MAC-eligible children 18 years of age. OUTCOME MEASURES: Claims data were used to define avoidable hospitalization (based on ambulatory care received before hospitalization), to define ACS hospitalizations (based on the International Classification of Diseases-Clinical Modification, Ninth Revision [ICD-9-CM] codes), and to summarize use of ambulatory and inpatient care. ACS hospitalizations have been defined as those conditions for which timely and effective primary care can help to reduce the risk of hospitalizations. These are based solely on ICD-9-CM discharge codes that were studied by Billings and Teicholz in 1990 and used by an Institute of Medicine report in 1993. Examples include hospital discharge diagnoses of asthma (ICD-9-CM = 493), gastroenteritis (ICD-9-CM = 558.9), and dehydration (ICD-9-CM = 276.5). Usage measures, such as preventive care visits or ED visits, were created using Maryland Medicaid codes, Current Procedural Terminology codes, and ICD-9-CM codes. Linear regression was used to model trend. Logistic regression was used to model the probability of ambulatory and inpatient care given MAC enrollment and other covariates. First, logistic regression was used to predict the probability of any ambulatory care use among all MAC-eligible children during a quarter to model changes in access that may have occurred during MAC. Then, among users of ambulatory care or inpatient care, logistic regression was used to predict the probability of hospitalization. RESULTS: Most of the children studied were in the AFDC program, about half were African-American, one third resided in Baltimore City, and 9% of children had ICD-9-CMs reflecting chronic disease. The mean percentage of time children were MAC-eligible per quarter was 91%. Only 5% of children were continuously enrolled for all 20 quarters included in this study. Per-capita ambulatory care visits, especially per-capita preventive care visits, increased significantly during the study period (b = 0.003) whereas per-capita ED visits did not change. The mean n

Adolescent↗
PubMed1996

Assessing Medicaid managed care in eastern state.

This case examines the expanding role of managed care programs in improving health care for the poor while controlling runaway health care costs. The case asks what the commissioner of health in a large eastern state should do to effectively monitor Medicaid managed care programs in her state. The commissioner faces intense pressures for cost containment and strong, but not universal, support for the managed care solution to health care cost problems. The commissioner is herself concerned that the cost savings attributed to managed care may not be real and that the unintended effects on health care may be adverse. Her immediate challenge is to determine what kinds of data she should require service providers to submit to her agency so that she may effectively monitor managed care programs for health care quality, provide positive feedback to health care providers, and establish politically credible program oversight.

Cost Control↗
PubMed1980

Meeting the health care challenge: improved program management.

The Health Care Financing Administration (HCFA) is the government agency that administers Medicaid and Medicare, and is responsible for standards and certification programs, and for Professional Standards Review Organizations. HCFA is attempting to improve program management, while securing the very best health care for the 47 million Medicare and Medicaid beneficiaries. Better management would allow resources to be focused where the greatest need exists and would thereby increase program effectiveness.

Government Agencies↗
PubMed2000

Oil and water? Lessons from Maryland's effort to protect safety net providers in moving to Medicaid managed care.

Studies have highlighted the tensions that can arise between Medicaid managed care organizations and safety net providers. This article seeks to identify what other states can learn from Maryland's effort to include protections for safety net providers in its Medicaid managed care program--HealthChoice. Under HealthChoice, traditional provider systems can sponsor managed care organizations, historical providers are assured of having a role, patients can self-refer and have open access to certain public health providers, and capitation rates are risk adjusted through the use of adjusted clinical groups and claims data. The article is based on a week-long site visit to Maryland in fall 1998 that was one part of a seven-state study. Maryland's experience suggests that states have much to gain in the way of "good" public policy by considering the impact of their Medicaid managed care programs on the safety net, but states should not underestimate the challenges involved in balancing the need to protect the safety net with the need to contain costs and minimize the administrative burden on providers. No amount of protection can compensate for a poorly designed or implemented program. As the health care environment continues to change, so may the need for and the types of protections change. It also may be most difficult to guarantee adequate protections to those who need it most--among relatively financially insecure providers that have a limited management infrastructure and that depend heavily on Medicaid and the state for funds to care for the uninsured.

Community Participation↗
PubMed1999

A conflict of strategies: Medicaid managed care and Medicaid maximization.

OBJECTIVE: To examine the influence of state strategies aimed at increasing federal Medicaid matching dollars on the design of states' Medicaid managed care programs. STUDY DESIGN: Data obtained from the 1996-1997 case studies of 13 states to examine how states have adapted the design of their Medicaid managed care programs in part because of maximization strategies, to accommodate the many roles and responsibilities that Medicaid has assumed over the years. PRINCIPAL FINDINGS: Our study showed that as states made the shift to managed care, some found that the responsibilities undertaken in part through maximization strategies proved to be in conflict with their Medicaid managed care initiatives. Among other things, the study revealed that most states included provisions that preserved the health care safety net, such as adapting the managed care benefit package and promoting the participation of safety net providers in managed care programs. In addition, most of the study states continued to pay special subsidies to safety net providers, including hospitals and clinics. CONCLUSIONS: States have made real progress in moving a large number of Medicaid beneficiaries into managed care. At the same time, many states have specially crafted their managed care programs to accommodate safety net providers and existing funding mechanisms. By making these adaptations states, in the long run, may compromise the central goals of managed care: controlling costs and improving Medicaid beneficiaries' access to and quality of care.

Economics, Hospital↗
PubMed1998

Multiple sclerosis care: an integrated disease-management model.

A disease-management model must be integrated, comprehensive, individual patient focused and outcome driven. In addition to high quality care, the successful model must reduce variations in care and costs. MS specialists need to be intimately involved in the long-term care of MS patients, while not neglecting primary care issues. A nurse care manager is the "glue" between the managed care company, health care providers and the patient/family. Disease management focuses on education and prevention, and can be cost effective as well as patient specific. To implement a successful program, managed care companies and health care providers must work together.

Combined Modality Therapy↗
PubMed1992

Initial level of care and clinical status in a managed mental health program.

Data from 9,055 adult intakes performed over two and a half years of a managed mental health care demonstration project in a large U.S. city were used as indirect measures of quality of care. The level of care to which patients were initially assigned was examined in relation to the patients' clinical status as judged by both managed care case managers and treatment providers. During the period, assignment to inpatient care of patients in almost every clinical category decreased. The decrease seemed to reflect a policy decision to limit use of all inpatient services rather than a selective elimination of unnecessary hospitalization. Case managers rated a smaller proportion of patients severely disturbed, partial hospitalization was rarely used as an alternative to inpatient care, and detoxification services were increasingly used as an inpatient alternative. Although these data reinforce common beliefs about managed care, the quality of managed care programs can be accurately assessed only with data collected specifically for evaluation purposes.

Alcoholism↗
PubMed2005

The impact of Medicaid managed care on hospitalizations for ambulatory care sensitive conditions.

OBJECTIVE: To determine whether Medicaid managed care is associated with lower hospitalization rates for ambulatory care sensitive conditions than Medicaid fee-for-service. We also explored whether there was a differential effect of Medicaid managed care by patient's race or ethnicity on the hospitalization rates for ambulatory care sensitive conditions. DATA SOURCES/STUDY SETTING: Electronic hospital discharge abstracts for all California temporary assistance to needy families (TANF)-eligible Medicaid beneficiaries less than age 65 who were admitted to acute care hospitals in California between 1994 and 1999. STUDY DESIGN: We performed a cross-sectional comparison of average monthly rates of admission for ambulatory care-sensitive conditions among TANF-eligible Medicaid beneficiaries in fee-for-service, voluntary managed care, and mandatory managed care. DATA COLLECTION/EXTRACTION METHODS: We calculated monthly rates of ambulatory care-sensitive condition admission rates by counting admissions for specified conditions in hospital discharge files and dividing the monthly count of admissions by the size of the at-risk population derived from a separate monthly Medicaid eligibility file. We used multivariate Poisson regression to model monthly hospital admission rates for ambulatory care-sensitive conditions as a function of the Medicaid delivery model controlling for admission month, admission year, patient age, sex, race/ethnicity, and county of residence. PRINCIPAL FINDINGS: The adjusted average monthly hospitalization rate for ambulatory care-sensitive conditions per 10,000 was 9.36 in fee-for-service, 6.40 in mandatory managed care, and 5.25 in voluntary managed care (p<.0001 for all pairwise comparisons). The difference in hospitalization rates for ambulatory care sensitive conditions in Medicaid fee-for-service versus managed care was significantly larger for patients from minority groups than for whites. CONCLUSIONS: Selection bias in voluntary Medicaid managed care programs exaggerates the differences between managed care and fee-for-service, but the 33 percent lower rate of hospitalizations for ambulatory care sensitive conditions found in mandatory managed care compared with fee-for-service suggests that Medicaid managed care is associated with a large reduction in hospital utilization, which likely reflects health benefits. The greater effect of Medicaid managed care for minority compared with white beneficiaries is consistent with other findings that suggest that managed care is associated with improvements in access to ambulatory care for those patients who have traditionally faced the greatest barriers to health care.

Adolescent↗
PubMed1990

Conservative management of temporomandibular joint disease: a case study.

Although temporomandibular joint (TMJ) problems are difficult to diagnose and evaluate, treatment today centers on conservative methods, not surgery. Many dentists lack the knowledge to adequately diagnose and treat TMJ, and many insurers as well as managed care plans have often refused to pay for conservative therapy, now known as Phase 1 TMJ treatment. This treatment consists of appliance or intraoral splint placement, along with physical therapy. Ultimately, this therapy is far less expensive than either joint or orthognathic surgery. Since there is no recognized specialty in TMJ disease, managed care programs need to establish discernible criteria for the selection of providers to diagnose and treat their TMJ patients. By carefully selecting providers and monitoring the outcome of treatment rendered to patients, costs and time of treatment could be drastically reduced, benefiting the patient and the managed care program.

Adolescent↗
PubMed1997

Application of the problem-based learning model for continuing professional education: a continuing medical education program on managed care issues--Part II.

Physicians must incorporate concepts of practice management and knowledge of managed care into their practices. Managed care presents an immediate and challenging opportunity to providers of continuing medical education to offer effective educational programs for physicians on managed care issues. In this exploratory research, the problem-based learning model was used to develop a continuing medical education program that would offer an interactive and effective method for teaching physicians about managed care. Problem-based learning is a departure from the traditional lecture format of continuing medical education programs because it is designed for small groups of self-directed learners who are guided by a faculty facilitator. Although only a small number of participants participated in this program, the findings offer important considerations for providers of continuing medical education. For example, participants reported increased confidence in their knowledge about managed care issues. Participants also clearly indicated a preference for the small group, interactive format of the problem-based learning model.

Education, Medical, Continuing↗
PubMed2007

The impact of managed care enrollment on emergency department use among children with special health care needs.

BACKGROUND: Many states recently have experimented with managed care as a way both to control costs and to enhance continuity of care in their publicly financed programs. A few states have applied managed care models to the care of chronically ill children. One marker for the effects of managed care is changes in use of the emergency department (ED). OBJECTIVE: We sought to determine whether a managed care program can reduce ED use for children with chronic health problems. SUBJECTS: We studied chronically ill children who were dually enrolled in Michigan's Title V program for children with special health care needs and Medicaid and who were enrolled in a managed care option at some time during the study period. The managed care model emphasized care coordination and did not include strong financial incentives for utilization and cost control. Sample consisted of 8580 person-months. METHOD: We used a fixed-effect negative binomial Poisson regression model to compare ED use before and after joining a managed care plan to test whether managed care use was associated with reduced likelihood of ED use. RESULTS: Managed care enrollment was associated with a 23% reduction in the incidence of ED use among children dually enrolled in Medicaid and Title V. CONCLUSIONS: A managed care model is associated with statistically significant and substantive reductions in observed use of ED care within an important population of children facing chronic illness.

Adolescent↗
PubMed2006

Risk for incident renal dialysis in a managed care population.

BACKGROUND: The influence of poorly controlled blood pressure (BP) on progression to end-stage renal disease typically has been studied in qualified populations. Few observational studies examined the influence of change in BP. METHODS: We conducted a retrospective observational study of a cohort of adults 18 years or older with glomerular filtration rates of 15 to 89 mL/min/1.73 m(2) (0.25 to 1.48 mL/s) in 2001 (N = 16,299) in a managed care organization. The cohort generally was representative of many urban areas in the United States. The principal outcome was incident renal dialysis in 2002 (N = 73). BP was measured in 1999 and 2001. Risk for incident dialysis therapy was estimated in the entire cohort by using Cox proportional hazards regression and in a subset of 4 randomly selected controls (n = 292) matched (for 2001 glomerular filtration rate, age, and sex) with incident dialysis cases by using conditional logistic regression. RESULTS: Within this cohort, dialysis incidence was 4.5 cases/1,000 adults. For incident dialysis cases, mean time to dialysis therapy in 2002 (from December 31, 2001) was 167 days. Greater levels of systolic or diastolic BP in 1999 were associated significantly with greater risk for incident dialysis treatment in 2002 (controlling for age, sex, coronary artery disease, diabetes, and tobacco use). Decreased systolic or diastolic BP from 1999 to 2001 was associated with significantly reduced risk for incident dialysis treatment in 2002. CONCLUSION: Improving BP control in adults with early or advanced kidney disease and moderately to severely elevated BP should continue to be a focus of care management programs seeking to decrease the risk for incident dialysis treatment.

Adolescent↗
PubMed1993

Improving access to the underserved through Medicaid managed care.

New York City's Harlem community faces extraordinary health care needs that a failing economy has made more urgent. In an attempt to open lines of access to health care, the New York City Health and Hospitals Corporation has implemented a managed care program for Medicaid participants. The program is a team approach to link each Medicaid patient with a primary care physician responsible for coordinating medical services for the patient. We hope the managed care program will help us conserve our dwindling resources while better managing patients' services and improving access to care.

Adolescent↗