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At least 253 records · Page 14Linked to original sources
PubMed1996

Population requirements for capitation planning in pediatric cardiac surgery.

OBJECTIVE: To determine the population number necessary to generate a sufficient volume of pediatric cardiac surgeries to allow accurate prediction of resource utilization. DESIGN: All pediatric cardiac surgical patients receive care in our institution by means of only four clinical pathways that are based on acuity, not diagnosis or procedure. This allows accurate tracking of resource utilization. Based on available information, 750 consecutive surgically treated patients were retrospectively assigned to a pathway. They were subsequently subdivided into study groups of decreasing sizes from 150 to 35. Variability of pathway distribution from group to group was examined as a measure of the ability to predict resource utilization based on group size. Pediatric cardiac statistics from the state of Ohio were then used to extrapolate to the population base necessary to generate each group size. SETTING: A regional pediatric cardiac referral center. PATIENTS: All sequential patients who underwent pediatric cardiac surgery between July 1991 and January 1994. RESULTS: Statewide statistics showed that a population base of 1 million people generates 100 pediatric cardiac operations. Groups of 100 patients or greater had minimal variation in pathway distribution from group to group, allowing accurate prediction of hospital charges. This was not true for groups of 50 patients or less. CONCLUSIONS: Resource utilization for pediatric cardiac surgery can be accurately predicted in a capitated setting for populations of 1 million covered lives (100 procedures) or greater. For populations of 500 000 covered lives or less, variability of case mix is great enough to suggest the need for a more individualized payment mechanism.

Capitation Fee↗
PubMed1997

Pediatric carve outs. The use of disease-specific conditions as risk adjusters in capitated payment systems.

OBJECTIVE: To address the issue of adverse selection in capitated payment systems by developing a list of disease-specific pediatric conditions (i.e., "carve outs") to be considered for separate reimbursement. DESIGN: A descriptive study using a large Medicaid database. INTERVENTION: With the use of fiscal year 1993 Washington State Medicaid cost data for 302,240 pediatric patients, a list of disease-specific carve outs was developed to meet the following criteria: high cost, low variability in cost, and association with a large proportion of medical spending. RESULTS: Six-hundred seventy-three patients (0.2%) in the database had annual costs totaling $25,000 or more. Ten percent of the cases accounted for approximately two thirds of spending, while the least expensive 70% of cases made up only 15% of the expenditures. Prematurity and complications of prematurity, neoplasms, congenital heart disease, organ transplantations, congenital anomalies, and respiratory problems were general categories of disease that met our criteria for a carve out. The association of a major surgical procedure with a diagnosis increased the predictive accuracy for high cost. CONCLUSION: Lists of disease-specific carve outs such as this one can be used by Medicaid plans and other insurers who are concerned about risk selection to identify conditions for separate reimbursement in capitated payment systems.

Adolescent↗
PubMed1996

Some economics of mental health 'carve-outs'.

We discuss the rationale for benefit carve-out contracts in general and for mental health and substance abuse in particular. We focus on the control of adverse selection as a principal explanation and find that this is consistent with the wide-spread use of sole-source contracting with periodic rebidding. We also find that some degree of risk sharing is common; we interpret this as a method of balancing cost-containment incentives with incentives to maintain access and quality on unmeasured dimensions.

Capitation Fee↗
PubMed1996

Enrollment duration, service use, and costs of care for severely mentally ill members of a health maintenance organization.

BACKGROUND: The rapid growth of prepaid health care and the increasing enrollment of Medicaid clients in health maintenance organizations (HMOs) raise concerns about the adequacy of services for persons with severe mental illness in capitated health plans. Uncontrolled studies have suggested that enrollment of HMO members with mental illness may be prematurely terminated. METHODS: We identified 250 adult Kaiser Permanente Northwest Region (Portland, Ore) members who were enrolled during 1986 or 1987 and had chart diagnoses of schizophrenia or bipolar disorder. Severely mentally ill subjects were matched by age and sex with control HMO members with and without diabetes mellitus. Records of the HMO and the state mental health agency were reviewed to determine HMO enrollment duration, private and public service utilization, and HMO costs of care during the 4-year follow-up period. RESULTS: The severely mentally ill subjects had 42 months of HMO enrollment during the follow-up period compared with 37 months for the controls without diabetes mellitus and 47 months for the patients with diabetes mellitus (P < .001). When HMO enrollment prior to the study was taken into account, the severely mentally ill subjects and those with diabetes mellitus had similar membership duration. Among the severely mentally ill subjects, community mental health service use was related to longer duration of HMO enrollment (P < .05) but HMO costs of care per member per month were not related to retention. The severely mentally ill subjects were high users of mental health services but their use of general medical care was similar to that of the controls without diabetes mellitus. CONCLUSIONS: This controlled study found no evidence for early termination of HMO members with costly mental illness. Use of community mental health care was associated with longer duration of HMO enrollment.

Adolescent↗
PubMed1995

TennCare--health system reform for Tennessee.

TennCare, the health care system reform plan implemented in Tennessee on January 1, 1994, was developed with the dual objectives of controlling the rapidly rising cost of the state's Medicaid program and extending health insurance coverage to most Tennesseans without access to employer-sponsored or other government-sponsored health insurance. Beneficiaries enroll in competing, state-chartered managed care organizations that are responsible for providing broad preventive, inpatient, and outpatient services and are reimbursed by the state on a capitation basis at a rate based on a statewide global budget for health care. The program initially proposed to enroll up to 1,775,000 citizens and was projected to result in a cumulative cost savings to Tennessee and the federal government of $7.2 billion by the end of the 5-year demonstration period. However, major start-up problems encountered by the state and by managed care organizations and limitations imposed by the government have significantly constrained these expectations. At the end of its first year, more than 1.2 million citizens were enrolled, but the program incurred a $99 million deficit. Managed care organizations and hospitals have reported major financial problems, and constituency groups--especially those representing physicians--have attempted to block the program. Our objective is to describe the design and rationale of TennCare and discuss key issues the plan continues to face that may affect its long-term success.

Capitation Fee↗
PubMed1998

Primary care physician compensation method in medical groups: does it influence the use and cost of health services for enrollees in managed care organizations?

CONTEXT: Growth of at-risk managed care contracts between health plans and medical groups has been well documented, but less is known about the nature of financial incentives within those medical groups or their effects on health care utilization. OBJECTIVE: To test whether utilization and cost of health services per enrollee were influenced independently by the compensation method of the enrollee's primary care physician. DESIGN: Survey of medical groups contracting with selected managed care health plans, linked to 1994 plan enrollment and utilization data for adult enrollees. SETTING: Medical groups, major managed care health plans, and their patients/enrollees in the state of Washington. STUDY PARTICIPANTS: Sixty medical groups in Washington, 865 primary care physicians (internal medicine, pediatrics, family practice, or general practice) from those groups and affiliated with 1 or more of 4 managed care health plans, and 200 931 adult plan enrollees. INTERVENTION: The effect of method of primary care physician's compensation on the utilization and cost of health services was analyzed by weighted least squares and random effects regression. MAIN OUTCOME MEASURES: Total visits, hospital days, and per member per year estimated costs. RESULTS: Compensation method was not significantly (P>.30) related to utilization and cost in any multivariate analyses. Patient age (P<.001), female gender (P<.001), and plan benefit level (P<.001) were significantly positively related to visits, hospital days, and per member per year costs. The primary care physician's age was significantly negatively related (P<.001) to all 3 dependent measures. CONCLUSIONS: Compensation method was not significantly related to use and cost of health services per person. Enrollee, physician, and health plan benefit factors were the prime determinants of utilization and cost of health services.

Capitation Fee↗
PubMed1998

Tennessee's failed managed care program for mental health and substance abuse services.

In July 1996, Tennessee initiated a managed mental health and substance abuse program called TennCare Partners. This publicly funded "carve-out" experiment started chaotically and soon deteriorated into a crisis. Many patients did not receive care or lost continuity of care, and the traditional "safety net" mental health system nearly disintegrated. This qualitative case study sought to ascertain the impact of the TennCare Partners program. It points out that the program's difficulties stemmed directly from a flawed design that spread funds previously earmarked for severely mentally ill patients across the entire Medicaid population. States contemplating similar reforms should strive to protect vulnerable patients by risk-adjusting capitation payments and by focusing resources on care for severely mentally ill persons. States should also minimize program complexity and ensure the accountability of managed care networks for their patients' behavioral health care needs.

Adult↗
PubMed1998

A conceptual model of the effects of health care organizations on the quality of medical care.

There has been a great deal of interest in recent years in developing measures of health care quality that can be used to characterize and study the effects of health plans. However, because of the recent emergence of diverse types of health care organizations, it is often difficult to know which parts of a plan should be combined for analysis purposes. Also, simple taxonomies of health maintenance organizations (eg, staff, independent practice associations, group, and network) no longer adequately describe the diverse types of organizations that have become common. In this article we describe these trends, explain why older taxonomies of health care plans are not adequate, and present a new framework for characterizing and studying the effects of diverse types of plans.

Capitation Fee↗
PubMed1998

Consolidation of medical groups into physician practice management organizations.

CONTEXT: Medical groups are growing and merging to improve efficiency and bargaining leverage in the competitive managed care environment. An increasing number are affiliating with physician practice management (PPM) firms that offer capital financing, expertise in utilization management, and global capitation contracts with health insurance entities. These physician organizations provide an alternative to affiliation with a hospital system and to individual physician contracting with health plans. OBJECTIVE: To describe the growth, structure, and strategy of PPM organizations that coordinate medical groups in multiple markets and contract with health maintenance organizations (HMOs). DESIGN: Case studies, including interviews with administrative and clinical leaders, review of company documents, and analysis of documents from investment bankers, the Securities and Exchange Commission, and industry observers. SETTING: Medical groups and independent practice associations (IPAs) in California and New Jersey affiliated with MedPartners, FPA Medical Management, and UniMed. OUTCOME MEASURES: Growth in number of primary care and specialty care physicians employed by and contracting with affiliated medical groups; growth in patient enrollment from commercial, Medicare, and Medicaid HMOs; growth in capitation and noncapitation revenues; structure and governance of affiliated management service organizations and professional corporations; and contracting strategies with HMOs. RESULTS: Between 1994 and 1996, medical groups and IPAs affiliated with 3 PPMs grew from 3787 to 25763 physicians; 65% of employed physicians provide primary care, while the majority of contracting physicians provide specialty care. Patient enrollment in HMOs grew from 285503 to 3028881. Annual capitation revenues grew from $190 million to $2.1 billion. Medical groups affiliated with PPMs are capitated for most professional, hospital, and ancillary clinical services and are increasingly delegated responsibility by HMOs for utilization management and quality assurance. COMMENT: Physician practice management organizations and their affiliated medical groups face the challenge of continuing rapid growth, sustaining stock values, and improving practice efficiencies while maintaining the loyalty of physicians and patients.

California↗
PubMed2000

Access to substance abuse treatment services under the Oregon Health Plan.

CONTEXT: The shift to Medicaid managed care has raised numerous concerns about access to publicly funded substance abuse treatment. The implementation of a capitated chemical dependency benefit within the Oregon Health Plan in 1995 provided an opportunity to study the impact of funding mechanisms on access. OBJECTIVES: To determine to what extent access to publicly funded substance abuse treatment changed following the shift to managed care in Oregon and to examine factors associated with that change. DESIGN: Analysis of statewide treatment and Medicaid eligibility data. SETTING AND PATIENTS: All Medicaid-eligible persons aged 12 to 64 years who were enrolled in the Oregon Health Plan during 1994 (88,320), 1996 (170,387), 1997 (160,929), or 1998 (149,877). MAIN OUTCOME MEASURES: Access rates (the number of unique individuals admitted to treatment during a calendar year divided by the average number of enrolled members) computed before (1994) and after (1997) implementation of the capitated benefit. Analyses were replicated with data for 1996 and 1998. RESULTS: The percentage of Medicaid-eligible persons admitted to substance abuse treatment programs during a calendar year increased from 5.5% of the average number of enrolled members per month in 1994 to 7.7% in 1997, following the shift to managed care. For 1996 and 1998, the rates were 6.9% and 7.7%, respectively. Access rates varied considerably among the 7 largest prepaid health plans after adjusting for case mix. Operating characteristics of these prepaid health plans, such as the method of reimbursing treatment providers, were significant predictors of access after controlling for member characteristics. CONCLUSION: According to our analyses, Medicaid-eligible persons in Oregon observed an increase in access to substance abuse treatment after a shift to managed care. JAMA. 2000;284:2093-2099.

Adolescent↗