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PubMed2003

Verification of a decision analytic model assumption using real-world practice data: implications for the cost effectiveness of cyclo-oxygenase 2 inhibitors (COX-2s).

OBJECTIVE: To verify the gastroprotective agent (GPA) rate assumption used in cost-effectiveness models for cyclo-oxygenase 2 inhibitors (COX-2s) and to re-estimate model outcomes using GPA rates from actual practice. METHODS: Prescription and medical claims data obtained from January 1, 1999, through May 31, 2001, from a large preferred provider organization in the Midwest, were used to estimate GPA rates within 3 groups of patients aged at least 18 years who were new to nonselective nonsteroidal anti-inflammatory drugs (NSAIDs) and COX-2 therapy: all new NSAID users, new NSAID users with a diagnosis of rheumatoid arthritis (RA) or osteoarthritis (OA), and a matched cohort of new NSAID users. RESULTS: Of the more than 319,000 members with at least 1 day of eligibility, 1900 met the study inclusion criteria for new NSAID users, 289 had a diagnosis of OA or RA, and 1232 were included in the matched cohort. Gastroprotective agent estimates for nonselective NSAID and COX-2 users were consistent across all 3 samples (all new NSAID users, new NSAID users with a diagnosis of OA or RA, and the matched cohort), with COX-2 GPA rates of 22%, 21%, and 20%, and nonselective NSAID GPA rates of 15%, 15%, and 18%, respectively. Re-estimation of the cost-effectiveness model increased the cost per year of life saved for COX-2s from $18,614 to more than $100,000. CONCLUSIONS: Contrary to COX-2 cost-effectiveness model assumptions, the rate of GPA use is positive and marginally higher among COX-2 users than among nonselective NSAID users. These findings call into question the use of expert opinion in estimating practice pattern model inputs prior to a product's use in clinical practice. A re-evaluation of COX-2 cost-effectiveness models is warranted.

Adult↗
PubMed1996

Managed care for workers' compensation: three years of experience in an "employee choice" state.

Managed care techniques are becoming increasingly available to manage the medical indemnity losses associated with injuries paid for under the workers' compensation system. The authors describe 3 years' experience of identifying and abating workplace hazards and medically managing cases utilizing a preferred provider organization established solely for workers' compensation cases. In the model described, the occupational physician/nurse case-management team coordinates the entire process, from prevention of accidents to facilitated return to work. During the study period (1992 to 1995), per-capita losses were reduced by 23%, from $241 in fiscal year 1992 (the year before the managed care initiative), to $185 in fiscal year 1995. (Hereafter, each year referred to indicates that fiscal year.) In 1992, 22 lost-time cases per 1000 employees occurred, whereas the number of lost-time cases in the years 1993 to 1995 averaged 12 to 14 per 1000 employees. The rate of "medical only" cases dropped significantly from 155 per 1000 in 1992 to 96 per 1000 in 1995. The per-capita amount of monies spent on medical care decreased from $81 in 1992 to $63 in 1995. The most significant savings in medical costs related to claims associated with new occupational injuries, injuries that occurred during the fiscal year. In 1992, the per-capita loss on such cases was $23 and in 1995 it was $13, a 43% decrease. The number of temporary/total days dropped significantly from 163 per 100 employees in 1992 to 70 days in 1995. Concurrently, the per-capita loss for temporary total disability was reduced from $53 in 1992 to $26 in 1995. Per-capita administrative costs, as well as other indemnity losses (predominantly permanent partial disability), decreased only slightly over the study period ($58 to $54 and $60 to $51, respectively). We feel that these results indicate that environmental-risk management and medical-care management can be integrated to produce substantial savings. It also suggest that managed-care techniques, which are becoming more available to employers, can even be applied in status that do not have managed care legislation.

Baltimore↗
PubMed1990

Services and charges by PPO physicians for PPO and indemnity patients. An episode of care comparison.

Physicians who participate in preferred provider organizations (PPOs) usually agree to various types of utilization review and sometimes discount their charges or agree to accept lower fees. This study was performed to determine whether they provided more or fewer services to their PPO patients than to their indemnity patients and whether the discounting resulted in lower expenditures for each episode of illness. In 1984, Metropolitan Life offered PPO coverage to Dade County (Florida) school board employees and dependents but only a standard indemnity plan to Dade County government employees and dependents. Episodes of care were examined for patients with chest pain, hypertension, joint pain, gastrointestinal or liver disorders, and lower back pain cared for by physicians who treated patients in both the PPO and indemnity employee groups. For PPO patients, charges per physician service were the same or lower, but total physician charges during an episode were higher. For services such as laboratory tests, diagnostic x-rays, and room and board, PPO and indemnity patients' charges were not significantly different.

Fees, Medical↗
PubMed2006

An examination of periodontal treatment and per member per month (PMPM) medical costs in an insured population.

BACKGROUND: Chronic medical conditions have been associated with periodontal disease. This study examined if periodontal treatment can contribute to changes in overall risk and medical expenditures for three chronic conditions [Diabetes Mellitus (DM), Coronary Artery Disease (CAD), and Cerebrovascular Disease (CVD)]. METHODS: 116,306 enrollees participating in a preferred provider organization (PPO) insurance plan with continuous dental and medical coverage between January 1, 2001 and December 30, 2002, exhibiting one of three chronic conditions (DM, CAD, or CVD) were examined. This study was a population-based retrospective cohort study. Aggregate costs for medical services were used as a proxy for overall disease burden. The cost for medical care was measured in Per Member Per Month (PMPM) dollars by aggregating all medical expenditures by diagnoses that corresponded to the International Classification of Diseases, 9th Edition, (ICD-9) codebook. To control for differences in the overall disease burden of each group, a previously calculated retrospective risk score utilizing Symmetry Health Data Systems, Inc. Episode Risk Groups (ERGs) were utilized for DM, CAD or CVD diagnosis groups within distinct dental services groups including; periodontal treatment (periodontitis or gingivitis), dental maintenance services (DMS), other dental services, or to a no dental services group. The differences between group means were tested for statistical significance using log-transformed values of the individual total paid amounts. RESULTS: The DM, CAD and CVD condition groups who received periodontitis treatment incurred significantly higher PMPM medical costs than enrollees who received gingivitis treatment, DMS, other dental services, or no dental services (p < .001). DM, CAD, and CVD condition groups who received periodontitis treatment had significantly lower retrospective risk scores (ERGs) than enrollees who received gingivitis treatment, DMS, other dental services, or no dental services (p < .001). CONCLUSION: This two-year retrospective examination of a large insurance company database revealed a possible association between periodontal treatment and PMPM medical costs. The findings suggest that periodontitis treatment (a proxy for the presence of periodontitis) has an impact on the PMPM medical costs for the three chronic conditions (DM, CAD, and CVD). Additional studies are indicated to examine if this relationship is maintained after adjusting for confounding factors such as smoking and SES.

Aged↗
PubMed1991

Mental health and selection of preferred providers. Experience in three employee groups.

While Preferred Provider Organizations (PPOs) are designed to contain the costs of health care, they may not be able to do so if sicker individuals opt not to use PPO providers. This study examined how level of mental health status and prior use of mental health services affected the decision to use or not use PPO providers for mental health care for employees enrolled in fee-for-service plans with a PPO option. Data were obtained from an employee survey and claims data on three large employee groups. It was not possible to examine effects of sickliness on the intent to select PPO providers for mental health care directly because about one half of employees could not identify who they would visit for mental health care or even how they would select a provider for such care. The intent to use PPO or non-PPO providers for general medical care, however, was not significantly associated with mental health status when other factors were controlled. Furthermore, among persons who used mental health services after implementation of the PPO option, those who had previously visited providers who were to become part of the PPO panel tended to stay with PPO providers, while those who previously visited providers who were not to enter the PPO panel subsequently selected away from PPO providers for mental health care. This pattern of results suggests that established individual patient-provider relationships, rather than sickliness, determined the selection of PPO versus non-PPO providers for mental health care for employees enrolled in these optional PPO fee-for-service plans.

Adult↗
PubMed1996

New assumptions concerning IPAs and cost of dental care.

OBJECTIVES: Previous studies suggest that fee-for-service (FFS) patients receive more treatment and at a greater cost than capitation patients. In this study treatment plans of dentists who are members of an independent practice association (IPA), a preferred provider organization (PPO), or who are paid their usual fee for service are compared. METHODS: A carefully selected and trained professional actor, with actual dental disease and recent radiographs, was sent to the offices of general practice dentists for an examination and treatment plan. To one group of dentists (n = 21) the patient said he was a member of a PPO plan served by that dentist, to a second group (n = 15) he said he was a member of an IPA plan served by that dentist, and to the third group (n = 19) he said he would pay by the traditional FFS method. RESULTS: IPA dentists recommended more restorations (mean = 9.60) than those in the PPO program (mean = 5.95) or those paid by the traditional FFS method (mean = 5.58). The anticipated mean cost to the patient was higher for the IPA dentists ($1,815.20) compared to the other two types (PPO = $1,186.24, FFS = $1,470.42). CONCLUSIONS: The IPA models studied in this investigation permitted dentists to charge copayments for most treatments beyond basic services. This type of IPA might be similar to a fee-for-service model that provides practitioners with an incentive to do more rather than less treatment.

Adult↗
PubMed1999

Treating depression in staff-model versus network-model managed care organizations.

OBJECTIVE: To compare primary care providers' depression-related knowledge, attitudes, and practices and to understand how these reports vary for providers in staff or group-model managed care organizations (MCOs) compared with network-model MCOs including independent practice associations and preferred provider organizations. DESIGN: Survey of primary care providers' depression-related practices in 1996. SETTING AND PARTICIPANTS: We surveyed 410 providers, from 80 outpatient clinics, in 11 MCOs participating in four studies designed to improve the quality of depression care in primary care. MEASUREMENTS AND MAIN RESULTS: We measured knowledge based on depression guidelines, attitudes (beliefs about burden, skill, and barriers) related to depression, and reported behavior. Providers in both types of MCO are equally knowledgeable about treating depression (better knowledge of pharmacologic than psychotherapeutic treatments) and perceive equivalent skills in treating depression. However, compared with network-model providers, staff/group-model providers have stronger beliefs that treating depression is burdensome to their practice. While more staff/group-model providers reported time limitations as a barrier to optimal depression treatment, more network-model providers reported limited access to mental health specialty referral as a barrier. Accordingly, these staff/group-model providers are more likely to treat patients with major depression through referral (51% vs 38%) or to assess but not treat (17% vs 7%), and network-model providers are more likely to prescribe antidepressants (57% vs 6%) as first-line treatment. CONCLUSIONS: Whereas the providers from staff/group-model MCOs had greater access to and relied more on referral, the providers from network-model organizations were more likely to treat depression themselves. Given varying attitudes and behaviors, improving primary care for the treatment of depression will require unique strategies beyond enhancing technical knowledge for the two types of MCOs.

Chi-Square Distribution↗
PubMed1990

Groups vie for lucrative managed care accreditation business.

The race is on to determine which organization will become the accreditation agency of choice for the managed care industry. At stake is enormous clout at the state and national levels--and a lot of money. Squaring off against the traditional accreditation leader, the Joint Commission on Accreditation of Healthcare Organizations, are: the National Committee for Quality Assurance, the American Association of Preferred Provider Organizations, and the Utilization Review Accreditation Commission.

Accreditation↗
PubMed1997

Evolution, growth, and status of managed care in the United States.

While under attack in the United States, managed care/competition is being viewed by a number of European and other countries as a remedy in their struggle to control rising health care costs. While many fundamentals of American managed care have their roots in the British health system, significant differences exist between the two systems. While managed care, which can be loosely defined as any system of delivering health services in which care is delivered by a specified network of providers who agree to comply with the care approaches established through a case management process, has had a 100-year history in the United States, it wasn't until the mid-1970's that it began to gain national recognition. All health maintenance organizations (HMOs) are managed care organizations (MCOs) but not all MCOs are HMOs. The two other categories of MCOs are, preferred provider organizations (PPOs) and point of service plans (POS). Currently, three-quarters of Americans with health insurance are enrolled in managed care plans and there are 160 million Americans enrolled in such plans. A major on-going debate occurring in the United States is in regard to the comparative quality of care provided by MCOs and traditional fee-for-service plans. The study results to date have been equivocal. Another controversial managed care issue is the use of gag clauses in contracts between the MCOs and their providers. These clauses limit providers from being totally open and honest with patients about, for example, alternative treatment possibilities or the details of provider reimbursement. Since the failure of U.S. health care reform in 1994, there has been a more focused turn to the marketplace to provide the impetus for reducing costs. As a result, health care plans and providers have become more like traditional businesses which must focus on the bottom line to survive. In a marketplace where purchasers of care look for low bidders, it should be remembered that the level and quality of care a society receives is usually commensurate with the level of resources that it is willing to expend.

Fee-for-Service Plans↗
PubMedDate not supplied

A national study of commercial health insurance and medicaid definitions of medical necessity: what do they mean for children?

OBJECTIVE: To analyze medical necessity standards used by state Medicaid agencies and the largest commercial insurers in the United States on the basis of criteria related to scope of health problems covered and requirements for effectiveness and cost. METHODS: Information was obtained from managed care contract documents used by the 45 state Medicaid agencies enrolling children into managed care organizations and from certificates of coverage used by the largest health maintenance and preferred provider organization insurers in each state. RESULTS: Commercial insurers are more likely than Medicaid agencies to articulate medical necessity standards that limit coverage to treatment for illnesses and injuries and to include stringent requirements for cost and evidence of effectiveness. CONCLUSION: To reduce the discretion retained by insurers in determining medical necessity, particularly around the scope of health problems covered, much greater clarity and uniformity in medical necessity language will be required in the future.

Child↗
PubMedDate not supplied

Job-based health insurance in 2001: inflation hits double digits, managed care retreats.

Drawing on the results of a national survey of 1,907 firms with three or more workers, this paper reports on several facets of job-based health insurance, including the cost to employers and workers; plan offerings and enrollments; patient cost sharing and benefits; eligibility, coverage, and take-up rates; and results from questions about employers' knowledge of market trends and health policy initiatives. Premiums increased 11 percent from spring 2000 to spring 2001, and the percentage of Americans in health maintenance organizations (HMOs) fell six percentage points to its lowest level since 1993, while preferred provider organization (PPO) enrollment rose to 48 percent. Despite premium increases, the percentage of firms offering coverage remained statistically unchanged, and a relatively strong labor market has continued to shield workers from the higher cost of coverage.

Cost Sharing↗
PubMed1998

Managing dental care versus managed dental care: looking south from north of the 49th parallel.

In the United States, aggregate expenditures on the largely private health care system, as a proportion of Gross National Product, exceed those of all other countries. Under private enterprise, the health care system in the United States grew as predicted by the underlying equation that more service volume equates to more revenue for hospitals and providers. Managed care is the response of for-profit health care organizations to meet the demands of U.S. corporations to contain the escalating costs of hospital, medical and other health care benefits for their employees. Managed health care has several models, but preferred provider organizations (PPOs) have been the model that has increased most rapidly. In contrast, managers of Canadian public dental programs plan, organize, direct and control more of the structures, processes and outputs to achieve desired outcomes for special groups. In Canada, the approaches to quality assurance, restraint of trade and the power of the professional lobby are different from the approaches in the United States. Nonetheless, the context of private dental care plans is very similar to the context that produced managed health care in the United States. Better management to meet demonstrated needs with evidence-based care can result in sustainable, adequately financed plans and avoid the deep-discount form of managed dental care.

Canada↗
PubMed1990

Member satisfaction in a staff-model health maintenance organization.

The results of a June 1988 member-satisfaction survey undertaken by a staff-model health maintenance organization (HMO) are presented, and implications for HMO management are discussed. Focus groups identified key reasons for consumer satisfaction; results were incorporated into a telephone survey that was administered to 600 households randomly selected from among enrollees and to an equal number of nonenrollees in the same region. Questions covered five areas: (1) importance-of-health-plan issues, (2) predictors of health-plan satisfaction, (3) importance-of-provider issues, (4) predictors of satisfaction with providers, and (5) demographics and use of services. Comprehensiveness of coverage was the most important factor in selection of a health plan; cost ranked second. Factors related to health-plan satisfaction included quality and quantity of plan physicians, access to specialists, and scope of benefits. Analysis of the dependent variable, perceived quality of physician care, revealed that physician technical skills, physician availability after hours, and equipment and facilities were among the highest-ranking factors. Enrollees were significantly more satisfied with their health plan overall than were members of preferred-provider organizations or indemnity health plans. Management concluded that member satisfaction was related to the number of physicians available and the ease of access to a preferred physician. Physician quality appeared to be the prime determinant of member satisfaction. Competition will spur health plans to place more interest on identifying and responding to member preferences.

Consumer Behavior↗
PubMedDate not supplied

Patient satisfaction and selected physician behaviors: does the type of practice make a difference?

This study was designed to show what specific physician characteristics lead to patient satisfaction and to compare satisfaction of patients using either prepaid or fee-for-service modes of payment within the same settings. We surveyed 1142 patients in five family practice clinics in rural and suburban areas of the North Central United States. Regression analysis of a seven-item satisfaction scale showed four significant factors that accounted for variance: sensitivity, is on time for appointments, follows up promptly, and provides personalized medical care. No meaningful differences were found between health-maintenance-organization and fee-for-service patients on these satisfactions. This study expands findings from previous research and raises more questions about reliable rating scales for complex physician/patient relations. Our methods can be used to investigate the effects of newer types of prepaid plans (including individual practice associations and preferred provider organizations) on patient satisfaction. The challenge for future investigations is to test and build reliable predictive models showing how physician characteristics, patient satisfaction, and quality of medical care affect each other in these more complex models of practice and reimbursement.

Adult↗
PubMed1992

Healthchoice: a managed health-care program for low-income uninsured workers.

The period in which we practice medicine is unprecedented in terms of the enormous changes that are taking place within the profession. Perhaps foremost among the changes is the manner in which the practice of medicine is organized. Historically, over the last 30 years we have witnessed the transition of substantial proportions of physicians as solo practitioners to professionals employed in one form or another by institutional management care systems. Further, from all indications, this change is continuing unabatedly. There are now more than 600 health maintenance organizations (HMOs), and their enrollment rates have been steadily increasing. More than 60 million Americans or about 30% of the insured population receive their medical care through HMOs and preferred provider organizations (PPOs). Moreover, it is estimated that in the year 2000, 90% of all Americans will be receiving their medical care from managed care systems. Clearly, the driving force behind these changes is the desire of third-party payers and the public at large to control health-care costs. We, of course, share this goal and are committed to working with the public and private sectors to accomplish this aim. Deborah L. Scott, director of the Wayne County Patient Care Management Systems, writes about HealthChoice, a model managed-care program in Detroit, Michigan. Ms Scott's article is being published in lieu of the President's Column.

Female↗
PubMed2003

Assessing the validity of insurance coverage data in hospital discharge records: California OSHPD data.

OBJECTIVE: To assess the accuracy of data on "expected source of payment" in the patient discharge database compiled by the California Office of Statewide Health Planning and Development (OSHPD). DATA SOURCES: The OSHPD discharge data for the years 1993 to 1996 linked with administrative data from the University of California (UC) health benefits program for the same years. The linked dataset contains records for all stays in California hospitals by UC employees, retirees, and spouses. STUDY DESIGN: The accuracy of the OSHPD data is assessed using cross-tabulations of insurance type as coded in the two data sources. The UC administrative data is assumed to be accurate, implying that differences between the two sources represent measurement error in the OSHPD data. We cross-tabulate insurance categories and analyze the concordance of dichotomous measures of health maintenance organization (HMO) enrollment derived from the two sources. PRINCIPAL FINDINGS: There are significant coding errors in the OSHPD data on expected source of payment. A nontrivial percentage of patients with preferred provider organization (PPO) coverage are erroneously coded as being in HMOs, and vice versa. The prevalence of such errors increased after OSHPD introduced a new expected source of payment category for PPOs. Measurement problems are especially pronounced for older patients. Many patients over age 65 who are still covered by a commercial insurance plan are erroneously coded as having Medicare coverage. This, combined with the fact that during the period we analyzed, Medicare HMO enrollees and beneficiaries in the fee-for-service (FFS) program are combined in a single payment category, means that the OSHPD data provides essentially no information on insurance coverage for older patients. CONCLUSIONS: Researchers should exercise caution in using the expected source of payment in the OSHPD data. While measures of HMO coverage are reasonably accurate, it is not possible in these data to clearly identify PPOs as a distinct insurance category. For patients over age 65, it is not possible at all to distinguish among alternative insurance arrangements.

California↗
PubMed1989

HMO update. Where are they headed?

Health maintenance organizations (HMOs) are undergoing major changes, among them the following: Enrollee growth will continue to be strong, although the rate of growth will diminish. HMOs will develop new product lines, such as offering preferred provider organizations and various cost management services. The competitive environment has become tougher. Quality of care concerns among the public are on the rise. Employers, while generally supportive of HMOs, are also questioning and changing their contractual relationships with them.

Economic Competition↗