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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↗
PubMed1998

The effects of a managed care educational program on faculty and trainee knowledge, attitudes, and behavioral intentions.

PURPOSE: To assess the state of managed care knowledge and attitudes and to evaluate the effects of a two-day course on participants' knowledge, attitudes, and behavioral intentions. METHOD: In 1996, the University of California, Davis, Medical School invited all medical students, residents, faculty, and administrators to participate in one of two sessions of a two-day course on managed care. Participants in the first session were given both pre- and post-course questionnaires. Participants in the second session were given only post-course questionnaires. The questionnaires measured objective knowledge, attitudes, and behavioral intentions. Participants (other than administrators) who completed the questionnaires also received a follow-up questionnaire six months after the seminar. RESULTS: The two sessions were attended by 818 UC Davis medical students, residents, faculty, and administrators: after excluding 33 non-physician administrators, 428 completed survey packets (55%) were available for full analysis. Before the course, participants in the first session correctly answered on average only 46% of 32 questions about managed care knowledge. Course attendance was associated with significant gains in knowledge (to 67% correct, p < .001) and a marked increase in appreciation for the cost-control effectiveness of managed care (from 3.35 to 3.98 on a five-point scale, p < .001). Knowledge gains were greatest among medical students; changes in attitudes and behavioral intentions were least among residents. Among respondents to a follow-up survey, the changes were partially sustained six months later. CONCLUSION: Within this academic medical center, baseline levels of managed care knowledge were low among faculty as well as among trainees, and attitudes reflected a blend of negativism and wishful thinking. An intensive two-day educational program effectively increased knowledge and changed selected attitudes among critical academic constituencies. Other academic medical centers may wish to consider presenting similar programs in order to orient their faculties and trainees to the economic realities of the foreseeable future.

Academic Medical Centers↗
PubMed2006

Implementing a depression improvement intervention in five health care organizations: experience from the RESPECT-Depression trial.

A growing body of research provides strong evidence for the effectiveness of programs to improve the primary care of depression based on the chronic care model. At the same time these changes are difficult to sustain in their original research settings and more difficult to widely disseminate in primary care practice. The RESPECT-Depression trial tested an implementation and dissemination strategy by working through five community-based health care organizations (HCOs) to implement the Three Component Model (TCM) for improving depression care. This report describes the results of extensive interviews of project principals, health care program managers, depression care managers, and practicing primary care clinicians to understand the characteristics of organizations and the intervention components that were associated with implementation and dissemination of the TCM. In two of the organizations all 29 participating practices continued the TCM, while all 31 practices from the other three organizations did not. Successful continuation and dissemination appeared to be related to a broadly shared vision and commitment among all levels of the organization, clearly articulated by clinical leadership, for pursuing a systematic change strategy to improve chronic care that included, but extended beyond, depression, independent of clear evidence for cost-effectiveness of expanding depression management. Factors associated with inability to sustain the TCM included lack of a shared change strategy throughout the organization and inability to rationalize an economic model of depression care.

Depression↗
PubMed2004

New directions in Medicare managed care.

The new Medicare Prescription Drug, Improvement, and Modernization Act of 2003 offers the most sweeping reforms to the Medicare program since its inception. The managed care benefit formerly offered by Medicare+Choice is greatly improved under Medicare Advantage. Now the nation's senior citizens in urban and rural areas alike can participate in PPOs that provide care-management programs and protection against catastrophic costs. They also receive the same kind of private health insurance options that have been available to the nation's work force.

Aged↗
PubMed1998

Accountability and quality in managed care: implications for health care practitioners.

The development of managed care plans is the most dramatic change in the USA's health care system in recent decades. Despite the widespread growth, society is increasingly concerned with the quality of managed care programs. This article addresses the regulatory pressures that are being placed on managed care organisations and examines what health care practitioners can do to minimize the impact of increased regulation. We look at the major factors that are likely to bring about changes in the health care sector, and predict how these changes will affect the quality of health care that is being delivered in the near future. Addresses how quality can become and remain the primary factor in the delivery of health care services. Finally, concludes that greater involvement by the federal government is necessary to protect consumers' rights, and ensure better quality health care from managed care programs.

Consumer Advocacy↗
PubMed2006

Diabetes disease management in Medicaid managed care: a program evaluation.

The objective of this study was to evaluate the outcomes of a diabetes disease management initiative among TennCare's Medicaid Population. A quasi-experimental group design was conducted using a control group and a diabetes disease management intervention group. Primary outcomes measures were rates for three key recommended tests (ie, microalbuminuria, lipids, and hemoglobin A1c). Secondary performance measures --patient satisfaction and program evaluation issues -- also were assessed. The study was performed among TennCare beneficiaries with diabetes mellitus. It utilized a quasi-experimental nonequivalent control group design, with 993 intervention participants in Knoxville and 1167 control group members in Chattanooga. Variables analyzed included testing rates for hemoglobin A1c, lipids, microalbuminuria, and demographics. A logistic regression model using baseline covariates was constructed to analyze the differences between the intervention and the control groups. Intracluster correlations were accounted for by generalized estimating equations. Statistical process control detected process changes in testing rates over time. There were meaningful changes in the rate of ordering recommended tests. The odds of an individual in the intervention group having at least one microalbuminuria test were 196% more (confidence interval [CI] = 1.50, 5.82; p = 0.002); the odds of having at least one lipid profile were 43% more (CI = 1.01, 2.02; p = 0.042); and the odds of having two or more hemoglobin A1c tests were 39% more (CI = 0.87, 2.23; p = 0.165) than the odds of an individual in the control group. The analysis also showed a high rate of satisfaction among patients in the intervention group. The program was successful in meeting its stated goals of providing effective disease management for TennCare patients with diabetes.

Adult↗
PubMed1998

Quality management by state Medicaid agencies converting to managed care: plans and current practice.

CONTEXT: Enrollment in Medicaid managed care plans has increased more than 5-fold in this decade, but how states monitor and encourage quality of care in these programs is not known. OBJECTIVE: To characterize the quality monitoring and assurance activities of state Medicaid agencies for Medicaid beneficiaries enrolled in comprehensive prepaid managed care programs. DESIGN: Structured telephone survey conducted between October 1996 and January 1997. SETTING: State Medicaid agencies. PARTICIPANTS: Representatives from all state Medicaid agencies, including the District of Columbia, with beneficiaries enrolled in comprehensive prepaid managed care plans as of July 1, 1996. MAIN OUTCOME MEASURES: Proportion of states with specific quality monitoring and assurance activities for Medicaid managed care. RESULTS: We surveyed all 34 states enrolling beneficiaries in comprehensive managed care programs. In 1996, all 34 states enrolled the population receiving assistance from the Aid to Families With Dependent Children (AFDC) program, while only 21 (62%) and 15 (44%) enrolled the disabled and elderly populations, respectively. In the period 1995 to 1996, 19 states (63%) collected data on satisfaction with care, and 25 states (83%) collected data on childhood immunizations. No more than half of the states collected data on other selected measures of access and quality, but a substantial number planned to collect such data in 1997. While at most 37% of states were providing comparative data to health plans, up to 80% were planning to provide such information in 1997. Similarly, while at most 10% of states provided beneficiaries with such information, up to 38% planned to do so in 1997. The breadth of contracting requirements designed to assure quality varied substantially across states. CONCLUSIONS: State Medicaid agencies have already begun adapting to their new roles as purchasers of health care. Continued monitoring is essential to ensure that state agencies implement planned programs and that quality of care for Medicaid enrollees is preserved or improved.

Health Care Surveys↗
PubMed2000

Effect of different types of Medicaid managed care on childhood immunization rates.

Medicaid managed care can improve access to prevention services, such as immunization, for low-income children. The authors studied immunization rates for 7,356 children on Medicaid in three managed care programs: primary care case management (PCCM; n = 4,605), a voluntary HMO program (n = 851), and a mandatory HMO program (n = 1,900). Immunization rates (3:3:1 series) in PCCM (78%) exceeded rates in the voluntary HMO program (71%), which in turn exceeded those in the mandatory HMO program (67%). Adjusting for race, urban residence, and gender, compared to children in PCCM, children in the voluntary HMO program were less likely to complete the 3:3:1 series (OR = 0.75, CI = 0.63, 0.90), and children in the mandatory HMO program were even less likely to complete the series (OR = 0.59, CI = 0.51, 0.68). Results differed by individual HMOs. Monitoring of outcomes for all types of managed care by Medicaid agencies is imperative to assure better disease prevention for low-income children.

Child, Preschool↗
PubMed1995

Relational triangles in managed care.

Relational triangles provide a conceptual framework for understanding interpersonal relationships and utilization review disputes in managed care programs. Relational triangles exist in the every day practice of medicine. The most striking example of relational triangles in practice is found in managed care systems' concurrent utilization management programs. The author provides some rules of relational triangles and vignettes to illustrate how they work in the managed care setting.

Communication↗
PubMedDate not supplied

Responding to managed care proposals.

To continue to use the term alternative delivery systems in relation to managed care is inappropriate, writes Darrell Schryver, D.P.A., since these systems are rapidly becoming the predominant method for delivering health care. Because such managed care programs are administered by individuals trained in business, it is imperative that medical practices adopt a similar business attitude to negotiate advantageously with these programs.

Economic Competition↗
PubMed2001

Selective contracting in managed care: the case of substance abuse treatment.

The authors address two critical questions concerning managed care and outpatient substance abuse treatment organizations. Specifically, they consider (1) to what extent selective contracting occurs between managed care firms and treatment providers and (2) what attributes of treatment providers and their operating environments are associated with selective contracting. Using data from a nationally representative sample of outpatient treatment organizations, the authors find evidence of systematic selection. Several indicators of providers' quality and costs, including accreditation status, private ownership, size, and prior experience with managed care, are positively associated with managed care contracting. By contrast, units providing methadone treatment are less likely to be involved in managed care. To a lesser extent, characteristics of treatment providers' operating environment, including extent of competition based on costs and attributes of the Medicaid managed care program, are also positively associated with managed care contracting.

Accreditation↗
PubMed2003

Use of the short form 36 in a primary care based disease management program for patients with congestive heart failure.

While disease management has been described as an important strategy for the care of patients with congestive heart failure (CHF) in the managed care setting, little is known about the impact of this approach on overall health-related quality of life. In this study the Short Form 36 (SF-36) was administered to all patients entering CHF disease management at the time of program entry and at 1 year following entry. Scores on the eight subscales and the two composite scales were calculated and compared before and after. Patients were enrolled from a mixed-model health maintenance organization (HMO) with 34,740 Medicare + Choice enrollees residing in 38 counties in central and northeastern Pennsylvania. Two hundred sixty-eight continuously enrolled patients in an HMO-sponsored CHF disease state management program with completed baseline and follow-up SF-36 surveys were sampled. All patients entered into disease management received primary care based, nurse-directed education about CHF self-management including instruction on etiology of CHF, the importance of medication compliance, home care services if indicated, monitoring weight gain, increased understanding of the warning signs of worsening CHF, and coaching on strategies to contact a physician in a timely manner when CHF worsens. Nurses also facilitated for CHF guidelines among primary care physicians, including the need to obtain a baseline assessment of cardiac function, prescribe angiotensin I-converting enzyme (ACE) inhibitors and beta blockers when appropriate, and initiated appropriate specialist referral. Compared with enrollees who did not complete a pair of SF-36 surveys, the 268 respondents were younger and had a significantly higher rate of cardiac imaging as well as use of ACE inhibitors and beta blocker medications. Analysis of the SF-36 data revealed that three of the eight (Role Physical, General Health Perceptions, and Role Emotional) subscales increased in a statistically significant manner, as did the Mental Health Composite Score. No statistically significant declines in SF-36 scores were observed. Despite limitations to our study, we found disease management for patients with CHF can be associated with significant improvements in quality of life as measured by the SF-36. Compared with nonrespondents, respondents had a higher prevalence of cardiac imaging, ACE inhibitor use, and beta blocker medication use. Our findings are also limited by a lack of a control group with the possibility that the improvements we observed were unrelated to the disease management intervention. However, our findings and success with the use of this tool indicate the SF-36 can be an important part of the ongoing assessment of patients in a disease management program for CHF.

Aged↗
PubMed1997

Advanced practice psychiatric-mental health nursing in a community-based nurse-managed primary care program.

In the evolving health care environment, advanced practice opportunities for psychiatric-mental health nurses may lie in managed care models of community oriented primary health care. As providers, care managers, health promoters and educators, and client advocates with family systems expertise, psychiatric-mental health advanced practice specialists are a necessary component of all primary health care. This article describes the development of a community-based primary care practice that integrates physical and mental health care on the same site.

Adult↗
PubMed1994

Characteristics of private-sector managed care for mental health and substance abuse treatment.

OBJECTIVE: This study examined diversity during the late 1980s in managed care programs for mental health, alcohol abuse, and drug abuse to identify ways in which research can generate more meaningful data on the effectiveness of utilization review programs. METHODS: Telephone interviews were conducted with representatives of utilization review programs for employee health insurance plans in 31 firms that employed 2.1 million people in 1990. Questions addressed qualifications of personnel, clinical criteria to authorize care, integration with employee assistance plans, penalties for not complying with utilization review procedures, outpatient review, and carve out of mental health and substance abuse review. RESULTS: Large variations in utilization review programs were found. Programs employed a range of review personnel and used a variety of clinical criteria to authorize care. More than two-thirds did not carve out mental health and substance abuse review from medical-surgical review. Some firms' employee assistance plans were integrated with utilization review programs, while others remained unintegrated. Penalties for not following program procedures varied widely, as did review of outpatient services. CONCLUSIONS: Because of trends toward even more diversity in utilization review programs in the 1990s, research that identifies the specific features of managed care programs that hold most promise for controlling costs while maintaining quality of care will increasingly be needed.

Alcoholism↗
PubMed2003

Do nonprofit HMOs eliminate racial disparities in cardiac care?

African-Americans have far less access to treatment for heart disease than similar white Americans. In this article, we explore the sector difference theory hypothesis that treatment provided by a nonprofit Medicaid managed care plan can reduce or even eliminate the race gap. Specifically, we compare the treatment offered to patients in for-profit Medicaid managed care programs to the treatment offered to similar patients in nonprofit Medicaid managed care programs. Data are from the Maryland Health Services Cost Review Commission and cover all patients discharged from hospitals in Maryland during calendar year 1998 with principal diagnoses indicating diseases of the circulatory system (ICD-9-CM codes 390 through 459) or chest pain (ICD-9-CM codes 786.50 through 786.52 and code 786.59). African-Americans were significantly less likely to receive the three treatments of interest, even after controlling for principal diagnosis, blood pressure, co-morbidities, and age. In regard to African-American access to treatment, there were no significant differences between the sectors.

Black or African American↗
PubMed2001

Public sector managed care for substance abuse treatment: opportunities for health services research.

Observations of reduced utilization of alcohol and drug abuse treatment following the introduction of managed behavioral health care suggest that substance abuse services may be especially responsive to managed care restrictions and limits. In publicly funded treatment systems, patient attributes, system and provider characteristics, and financing mechanisms may heighten susceptibility to unintended effects. The State Substance Abuse and Mental Health Treatment Managed Care Evaluation Program reviewed state managed care programs for publicly funded alcohol and drug treatment services and is evaluating programs in Arizona, Iowa, Maryland, and Nebraska. The article describes initiatives and outlines evaluation activities. It discusses the opportunities and challenges of assessing public managed care plans.

Arizona↗
PubMed1998

Commentary: Medicaid reform issues affecting the Indian health care system.

Substantial numbers of Indian people rely on Medicaid for their primary health insurance coverage. When state Medicaid programs enroll Indians in managed care programs, several unintended consequences may ensue. This paper identifies some of the perverse consequences of Medicaid reform for Indians and the Indian health care system and suggests strategies for overcoming them. It discusses the desire of Indian people to receive culturally appropriate services, the need to maintain or improve Indian health care system funding, and the duty of state governments to respect tribal sovereignty. Because of their relatively small numbers, Indians may be treated differently under Medicaid managed care systems without significantly endangering anticipated program savings. Failure of Medicaid programs to recognize the uniqueness of Indian people, however, may severely weaken the Indian health care system.

Eligibility Determination↗