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To optimize the benefits of managed care delivery systems, employers must identify and reward those systems that are most efficient and effective. At the same time, their deeper involvement in system design and management exposes employers to greater potential liability. Employers thus need to better evaluate their managed care programs in order to enhance the benefits and minimize the risks.
Mandatory managed-care programs for Medicaid beneficiaries typically require enrollees to select the provider who will act as gatekeeper to the medical care system. A substantial number of beneficiaries, however, do not exercise this choice and are assigned a gatekeeper. Using consumer survey data from the Missouri Managed Health Care Project, we examined characteristics and use experiences of assignees compared with selectors. We found that the assignees enjoyed better health than the selectors and were less likely to have had a regular source of care prior to the program. The utilization experience was similar for both groups. We conclude that the basis for not making a choice is one of indifference.
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This study compared interactive and noninteractive smoking cessation interventions for a population of smokers who were all members of 1 division of a managed care company. In addition, it examined whether a dose-response relationship existed. Screening was completed for 19,236 members who were contacted by telephone or mail. Of the 4,653 who were identified as smokers, 85.3% were enrolled. A 2 Intervention (interactive or noninteractive) x 4 Contacts (1, 2, 3, or 6 contacts) x 4 Occasions (0, 6, 12, and 18 months) design was used. The interactive intervention was stage-matched expert-system reports plus manuals; the noninteractive intervention was stage-matched manuals. Contact occurred in 1 of 4 series (1, 2, 3 or 6 contacts) at 3-month intervals. The expert system outperformed the stage-matched manuals, but there was no clear dose-response relationship for either intervention.
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Explore the source record for details and available documents.
Explore the source record for details and available documents.
Explore the source record for details and available documents.
Explore the source record for details and available documents.
Explore the source record for details and available documents.
This paper reports on The Hospital of the University of Pennsylvania's experience and concerns as a participating primary care site in a Medicaid managed care program (HealthPASS), which was established in 1986. Enrollment is mandatory for approximately half of Philadelphia's medical assistance population. Participating primary care sites receive monthly capitation for enrollees and serve as "gatekeepers" for specialty and inpatient services. The report discusses why the academic medical center chose to participate in the program and how existing activities were modified to meet both increased demand for primary care and increased administrative requirements. It also identifies characteristics of the HealthPASS program and of the medical center that have impeded effective case management of care for the urban poor population that the program serves. Improving the quality of care for the medically indigent while controlling costs is essential, but political realities and the special needs of the Medicaid population must be acknowledged. Increased attention must be given to the impact that political compromises have on the design and effectiveness of a managed care program.
OBJECTIVES: This study examined tuberculosis screening among preschool children enrolled in a statewide Medicaid managed care program. METHODS: A random sample of 2,000 was selected from 19 to 35 month old children who were continuously enrolled in Rhode Island's Medicaid managed care program for 1 year. Sociodemographic data were obtained from computerized administrative databases. Medical record audits were performed to obtain the dates and results of tuberculosis tests. RESULTS: Data from the medical record audits were available for 1,988 of the study children. For 1,215 of the study children (1,215/1,988 = 61%) a tuberculin skin test had been performed, but a reading was only documented for 736 children (60% of children who received a tuberculin skin test) and only one child tested positive (0.1%). CONCLUSIONS: A majority of preschool children in this population in which the prevalence of risk factors for tuberculosis is likely to be relatively high did have a tuberculosis test performed. However, in many cases the tuberculin skin test was either not read or the results not documented. The low rate of positivity is consistent with current AAP guidelines for selective tuberculin skin testing.
Coordination and collaboration between organizations interested in promoting the health of the populations they serve can potentially help to ensure that key services are provided as well as augment the efforts beyond that which could be accomplished by each organization alone. Understanding the perspectives of each organization can facilitate development of health promotion initiatives that will be of mutual benefit. In Maryland, when a Medicaid managed care program was initiated, Memoranda of Understanding were signed between each managed care organization (MCO) and each of the 24 local health departments; many stipulated that the parties will coordinate on community health issues. This report describes a telephone survey of the health departments that was performed by one MCO to better understand the interests and expectations of the health departments and discusses a process for developing a community health promotion agenda for an MCO.
The success of managed care cost containment innovations depends on many factors, including how courts decide litigation challenging various cost containment initiatives. Although such litigation is just emerging, enough cases have been reported to enable an initial assessment of court rulings. To date there is no evidence that courts have systematically impeded cost containment initiatives. Few courts seem willing to usurp legislative choices in formulating health policy or to obstruct the market in organizing and delivering health care services. The anticipated role of the courts as policymakers in shaping health care delivery has yet to emerge.
This article examines the possibilities and limitations of using computerized insurance claims and outpatient medical records to evaluate a Medicaid managed care program. The quality of medical care delivered to enrollees 1 1/2 years into the MassHealth managed care program's operation is discussed in the context of an evaluation that was conducted by the University of Massachusetts-Boston's McCormack Institute in 1993. Study results suggest that these two data sources offer adequate information to determine the quality level of primary and preventive services and lead to further suggestions for evaluating care.
Hospitals generally have been slow to get involved in public-sector managed-care programs, even though proponents say the programs increase provider reimbursement and improve access to care, but hospitals' fear of managed care and a lack of cooperation between physicians and hospitals on the programs may doom a nationwide hospital-sponsored managed-care approach.
OBJECTIVE: This study sought information about the effect of managed care on substance abuse treatment programs through a survey of program directors. METHODS: Fifty program directors who supervised a total of 134 substance abuse treatment programs in Los Angeles County completed a survey during the period from January to May 1997 on program changes made in response to managed care, major concerns, the advantages and disadvantages of managed care, and plans for further program changes to succeed in the managed care environment. RESULTS: Program directors reported that the most frequent change made in response to managed care was increased outreach and marketing. Their greatest concern in the managed care environment was being forced to provide the least costly service, rather than the best care for patients. Respondents identified an increased focus on outcomes as an advantage of managed care and restrictions on services due to contractual agreements as a disadvantage. Planned program changes addressed the areas of program structure, types of programs offered, staff composition, revenue generation, referral sources, prevention, outcome measures, relationships with other organizations, and accreditation and certification. CONCLUSIONS: Although some substance abuse treatment programs seem to be reducing their scope or preparing to close in response to managed care, others are developing strategies to survive and even thrive in this new economic environment.
OBJECTIVE: To describe the challenges of implementing a disease management program in a managed care environment. SUMMARY: A key element in the successful management of depression is ensuring persistent consumption of medication throughout the duration of a standard course of therapy. However, treating physicians rarely have easy access to the exact records necessary to determine medication persistence. Prescription claims databases do contain this information. Properly identifying problem consumption patterns from these data is one of the most valuable services that managed care pharmacists can provide in a disease management program. The experiences of Aetna Inc. in implementing a depression management program illustrate some of the most important factors to be considered when designing a program: obtaining approval from senior management, measuring baseline performance before program initiation, selecting plan members and physicians based on patterns of consumption in prescription claims data, and quantifying effectiveness. CONCLUSION: A visual representation of prescription refill dates and quantities available in prescription claims databases allowed member physicians to determine, at a glance, each patient.s medication persistence. Such representations of data are valuable for helping identify problem consumption patterns that require further analysis, such as noncontinuous treatment, low usage, and nonpersistence. However, such data are not recommended for use in a vacuum. that excludes considerations such as therapeutic indication and environment.