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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↗
PubMed1995

Rehabbing Medicare. Is managed care a cure-all or just a crutch?

Money, or the prospect of saving it, is what's rallying many in Congress around supporting managed care as Medicare's magic bullet. And financial, as well as community, incentives are certainly helping to push Medicare managed care programs forward in the delivery system. But will those programs accomplish everything their advocates expect?

California↗
PubMed1997

The impact of managed care on Massachusetts mental health and substance abuse providers.

Medicaid managed care programs are becoming more widespread. To investigate the clinical, organizational, and financial impacts on service providers, a stratified, random sample of providers in the Massachusetts Managed Mental Health/Substance Abuse Program were surveyed by phone in Years 3 and 4 of the initiative. Providers reported that they were making widespread clinical changes such as more use of group, brief, and episodic therapies. They were increasing utilization review, Total Quality Management, and outcomes measurement. They were increasing in size, affiliating with other agencies, and providing a greater range of services. They were preparing for capitation. Compared to before the program and a year earlier, about 40 percent of providers were doing better financially and a quarter were doing worse. The study documents the hypothesis that a widespread and continuing transformation is taking place in response to managed care.

Cost Control↗
PubMed1996

Contracting for Medicaid managed care.

State and Federal officials are turning to managed care to help control the costs of providing healthcare services to Medicaid recipients. However, most managed care plans and providers have little experience with this unique population. The socioeconomic profile, medical needs, healthcare utilization, and cost patterns of Medicaid recipients are very different from those of the commercial population. Managed care plans and providers that want to participate in Medicaid managed care programs must develop new approaches to providing benefits and developing capitation rates.

Capitation Fee↗
PubMed1993

Community-based home-care program for the management of pre-eclampsia: an alternative.

OBJECTIVE: To evaluate the safety, acceptability and cost of a community-based home-care program for the management of mild pre-eclampsia. DESIGN: A descriptive study of outcomes between Apr. 1, 1985, and Dec. 31, 1989. SETTING: St. Boniface General Hospital, Winnipeg. PATIENTS: Urban Winnipeg residents between 27 and 40 weeks' gestation with mild pre-eclampsia who demonstrated acceptance and compliance with home-care management; 321 patients of 1330 were enrolled in the program. INTERVENTIONS: Bed rest at home with daily biochemical and biophysical follow-up protocol and weekly clinic visits; patient education; hospital admission for labour, induction, worsening pre-eclampsia or noncompliance with rest at home. OUTCOME MEASURES: Patterns of referral to the program; clinical, biochemical and biophysical profiles; incidence of severe complications; reduction in total hospital stay and cost analysis. RESULTS: As many women were referred from physicians' offices as were referred from the hospital's antepartum unit, the average gestational age at referral being 36 weeks. Most (205 [64%]) of the women were nulliparous. The average length of stay in the program was 11.5 days. The program's availability resulted in a reduction of 2 days (from 5.7 days to 3.7 days) on average in the length of hospital stay when analysed for all 1330 women with pre-eclampsia. Of the 321 patients in the program 137 (43%) were admitted to hospital for worsening pre-eclampsia; severe pre-eclampsia developed 4 days after admission in 9. No patient suffered eclampsia, disseminated intravascular coagulopathy, abruption or fetal loss related to pre-eclampsia while in the program. The estimated cost saving in the management of pre-eclampsia was over $700,000 over the study period. CONCLUSION: The community-based home-care program is a safe, feasible and less costly alternative to hospital admission in the management of mild pre-eclampsia.

Cost Savings↗
PubMed2001

Does managed care enable more low income persons to identify a usual source of care? Implications for access to care.

BACKGROUND: By requiring or encouraging enrollees to obtain a usual source of care, managed care programs hope to improve access to care without incurring higher costs. OBJECTIVES: (1) To examine the effects of managed care on the likelihood of low-income persons having a usual source of care and a usual physician, and; (2) To examine the association between usual source of care and access. RESEARCH DESIGN: Cross-sectional survey of households conducted during 1996 and 1997. SUBJECTS: A nationally representative sample of 14,271 low-income persons. MEASURES: Usual source of care, usual physician, managed care enrollment, managed care penetration. RESULTS: High managed care penetration in the community is associated with a lower likelihood of having a usual source of care for uninsured persons (54.8% vs. 62.2% in low penetration areas) as well as a lower likelihood of having a usual physician (60% vs. 72.8%). Managed care has only marginal effects on the likelihood of having a usual source of care for privately insured and Medicaid beneficiaries. Having a usual physician substantially reduces unmet medical needs for the insured but less so for the uninsured. CONCLUSIONS: Having a usual physician can be an effective tool in improving access to care for low-income populations, although it is most effective when combined with insurance coverage. However, the effectiveness of managed care in linking more low-income persons to a medical home is uncertain, and may have unintended consequences for uninsured persons.

Adult↗
PubMed2004

Measurement comparisons of the medical outcomes study and veterans SF-36 health survey.

The Medicare Health Outcomes Survey (HOS) uses the Medical Outcomes Study (MOS) SF-36 among beneficiaries enrolled in Medicare managed care programs, whereas the Department of Veterans Affairs (VA), Veterans Health Administration (VHA) has administered the Veterans version of the SF-36 for quality management purposes. The Veterans version is comparable to the MOS version for 6 of the 8 scales, but distinctly different in role physical (RP) and role emotional (RE) scales. The gains in precision for the Veterans SF-36 provide evidence for the use of this version in future applications for assessing patient outcomes across health care systems.

Aged↗
PubMedDate not supplied

Constructing a conflict resolution program for health care.

Resolving conflict throughout organizations requires a programmatic infrastructure and a committed management team. Leaders must recognize the need to approach conflict by building a format for learning, creating and managing an effective conflict management program. Careful attention to the elements of design and the stages of development can make all the difference in building a sustainable and useful conflict management approach.

Confidentiality↗
PubMed2002

An evaluation of a Medicaid managed maternity program: the impact of comprehensive care coordination on utilization and pregnancy outcome.

The purpose of this study is to evaluate the effectiveness of the implementation of a Medicaid managed maternity care program in a public health department service population, analyzing race-specific models of WIC participation and risk of small-for-gestational age of term. There were 13,095 singleton deliveries during the period 1987-1990 to women with prenatal care in this managed maternity care program. The research design entailed comparison of the intervention group (those receiving regular prenatal care plus comprehensive care coordination in 1989-90) with an historical comparison group of women who received only regular prenatal care in the two years (1987-88).

Alabama↗
PubMed1992

Managed care strategies for the '90s.

With the proportion of patient care activity controlled by managed care organizations skyrocketing, providers need to study managed care trends, understand their strategic implications, and devise a response to them. Tremendous opportunities exist for hospitals that offer their own managed care programs, as long as they can avoid making costly mistakes. A critical tool is an overall strategy that includes collaboration with physicians, internal organization to manage risk, and direct contracting.

Contract Services↗
PubMed2005

Medicaid managed care and health care for children.

OBJECTIVE: Many states expanded their Medicaid managed care programs during the 1990s, causing concern about impacts on health care for affected populations. We investigate the relationship between Medicaid managed care enrollment and health care for children. DATA SOURCES AND MEASURES: Repeated cross-sections of Medicaid-covered children under 18 years of age from the 1996/1997 and 1998/1999 Community Tracking Study Household Surveys (n=2,602) matched to state-year CMS Medicaid managed care enrollment data. For each individual, we constructed measures of health care utilization (provider and emergency department visits, hospitalizations, surgeries); health care access (usual source of care, unmet medical needs, put-off needed care); and satisfaction (satisfaction overall, with doctor choice, and with last visit). STUDY DESIGN: Regression analysis of the relationship between within-state changes in Medicaid managed care enrollment rates and changes in mean utilization, access, and satisfaction measures for children covered by Medicaid, controlling for a range of potentially confounding factors. PRINCIPAL FINDINGS: Increases in Medicaid health maintenance organization (HMO) enrollment are associated with less emergency room use, more outpatient visits, fewer hospitalizations, higher rates of reporting having put off care, and lower satisfaction with the most recent visit. Medicaid primary care case management (PCCM) plans are associated with increases in outpatient visits, but also with higher rates of reporting unmet medical needs, putting off care, and having no usual source of care. CONCLUSIONS: Both Medicaid HMO and PCCM plans can have important impacts on health care utilization, access, and satisfaction. Some impacts may be positive (e.g., less ED use and more outpatient provider use), although concern about increasing challenges in access to care and satisfaction is also warranted.

Adolescent↗
PubMed2001

The Minnesota Senior Health Options program: an early effort at integrating care for the dually eligible.

BACKGROUND: Duplication of funding and resultant inefficiencies have prompted active consideration of pooling the funding for persons covered by both Medicare and Medicaid into a single managed care program. This study reports the initial results of the first such program. METHODS: A sample of enrollees in Minnesota Senior Health Options (MSHO) and two sets of controls (within the same catchment area and outside it) as well as their families were interviewed to assess their functional status and satisfaction with their medical care. Respondents included those living in the community and those living in nursing homes. RESULTS: The MSHO and control samples were generally alike in terms of demographics and illness patterns. The differences that were found reflected those attributable to geographic location more than program. The groups were also similar with regard to functional status. There were few satisfaction differences among the community-dwelling samples, but the MSHO nursing residents and especially their families expressed more satisfaction with several aspects of care. CONCLUSIONS: Whereas no causal conclusions about outcomes can be drawn from a cross-sectional sample, there is no indication that managed care for the dually eligible population has profound impacts on care. However, the system of care provided to nursing home residents is appreciated over traditional care.

Aged↗
PubMed2001

The effect of Medicaid managed care on rural public health departments.

Medicaid managed care programs are now operating in more than half of all rural counties in the United States. This study examines how rural health departments that have historically provided clinical services have responded to and been affected by the implementation of Medicaid managed care. To the extent that rural health departments have changed, the effect of this change on the health department and the rural populations that these providers serve is assessed. Site visits were made to four rural public health departments in each of five study states, for a total of 20 case studies. At each site, in-person interviews of county public health department directors were conducted using semistructured interview protocols. In recent years, the majority of health departments decreased or discontinued provision of well-child services, causing many to lose Medicaid revenue. None of the health departments appeared to be in danger of closing, but most lost income security. Medicaid managed care appeared to have increased the number of children with medical homes in the private sector, but adequacy and continuity of care remains an issue. Privatizing Medicaid managed care has not decreased fragmentation, as public health functions such as tracking and screening represent an important facet of comprehensive health services for poor rural populations.

Administrative Personnel↗
PubMed2006

Insights from a national survey into why substance abuse treatment units add prevention and outreach services.

BACKGROUND: Previous studies have found that even limited prevention-related interventions can affect health behaviors such as substance use and risky sex. Substance abuse treatment providers are ideal candidates to provide these services, but typically have little or no financial incentive to do so. The purpose of this study was therefore to explore why some substance abuse treatment units have added new prevention and outreach services. Based on an ecological framework of organizational strategy, three categories of predictors were tested: (1) environmental, (2) unit-level, and (3) unit leadership. RESULTS: A lagged cross-sectional logistic model of 450 outpatient substance abuse treatment units revealed that local per capita income, mental health center affiliation, and clinical supervisors' graduate degrees were positively associated with likelihood of adding prevention-related education and outreach services. Managed care contracts and methadone treatment were negatively associated with addition of these services. No hospital-affiliated agencies added prevention and outreach services during the study period. CONCLUSION: Findings supported the study's ecological perspective on organizational strategy, with factors at environmental, unit, and unit leadership levels associated with additions of prevention and outreach services. Among the significant predictors, ties to managed care payers and unit leadership graduate education emerge as potential leverage points for public policy. In the current sample, units with managed care contracts were less likely to add prevention and outreach services. This is not surprising, given managed care's emphasis on cost control. However, the association with this payment source suggests that public managed care programs might affects prevention and outreach differently through revised incentives. Specifically, government payers could explicitly compensate substance abuse treatment units in managed care contracts for prevention and outreach. The effects of supervisor graduate education on likelihood of adding new prevention and outreach programs suggests that leaders' education can affect organizational strategy. Foundation and government officials may encourage prevention and outreach by funding curricular enhancements to graduate degree programs demonstrating the importance of public goods. Overall, these findings suggest that both money and professional education affect substance abuse treatment unit additions of prevention and outreach services, as well as other factors less amenable to policy intervention.

Community-Institutional Relations↗
PubMedDate not supplied

Medi-Cal managed care.

Managed care programs may give California communities a cost effective way to provide health care to a growing Medi-Cal population. In this issue California Hospitals explores the benefits and risks of these programs.

Arizona↗