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↗
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Towards improving health care delivery for people with physical disabilities: findings from focus groups with health care consumers in Minnesota.
Specialized managed care programs such as the MnDHO program can improve the health care experience for people with disabilities if they include seamless care coordination among disability competent providers and promote consumer participation. Findings indicate greater satisfaction with care coordination, consumer participation, and provider knowledge in the AXIS/UCare complete program.
Adolescent↗
New developments in managed care litigation.
This article discusses recent litigation attempting to impose liability for managed care decisions on alternative delivery systems and recent state legislation allocating such liability among the participants in managed care programs.
Delivery of Health Care↗
An evaluation of a Medicaid managed maternity program: the impact of comprehensive care coordination on utilization and pregnancy outcomes.
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). For the intervention groups, black women were 1.7 times and white women 2.1 times more likely to participate in WIC than their comparison groups. The impact of care coordination on term-SGA births indicates a protective odds ratio of 0.851 for black women. Results for white women were not significant. These findings suggest that care coordination is associated with an increase in WIC participation and with lower risk of term-SGA births for black women but not for white women. The overall results add to growing evidence regarding the efficacy of comprehensive care coordination in improving specific pregnancy outcomes and inform our understanding of the evaluation of a comprehensive approach in preventive, community-based intervention.
Adolescent↗
The impact of managed care in dentistry.
Managed care plans attempt to control health care expenditures aggressively. These plans directly influence access to medical care and the type, level, and frequency of care rendered. As a result, hospital stays are reduced, focus shifts from inpatient to outpatient care, and patients are responsible for a larger share of health care costs. Dentistry is not immune from the impact of managed care. The attractiveness of the dental market has drawn many managed care organizations, insurers, and entrepreneurs to encourage dentists to participate in a wide variety of managed care programs. However, the delivery of dental care differs markedly in many respects from that of medical care. Therefore, many of the cost saving aspects of managed care that have been so successful in medicine may not result in similar cost savings in dentistry.
Capitation Fee↗
Managed care and the quality of children's health services.
Managed care has changed the practice of medicine. The choice of health care providers has been narrowed, physicians are being held financially accountable for the number of services they use, and a new emphasis is being placed on the cost and quality of the care provided. The transition to managed care has occurred with little attention to its impact on access to health care services or the quality of services provided. There is an absence of information about how children fare in these new systems. What little is known indicates that children in managed care arrangements are less likely to be able to be seen by pediatric specialists, and that families and providers are less satisfied under managed care. The impact of these changes on children's health status, however, is yet to be determined. For children with special needs, the problems of coordination of care, coverage of needed services, and the choice of the appropriate pediatric subspecialists, many of which existed in traditional fee-for-service systems, persist under managed care. In spite of all of the negative anecdotes about managed health care, managed care's focus on its population of enrollees and its heightened sense of a need for health care accountability bring exciting new opportunities to measure and improve the health care children receive. A new emphasis is being placed on practicing evidence-based medicine; the focus is on closing the gap between what is known (effective, evidence-based care) and what is done (current practice). Improved health outcomes and reduced health care costs have been documented in demonstration projects in neonatal intensive care units and in pediatric offices. Applying the principles of these learning collaboratives and employing the tools of continuous quality improvement in health care are urgent challenges that deserve to be met. Health plans, physicians, health care purchasers, regulators, families, and their children must work together to assure that children receive the highest-quality care possible--care that is technically excellent and medically appropriate, and that improves the health of our children.
Child↗
Civil rights in a changing health care system.
Title VI of the 1964 Civil Rights Act prohibits discriminatory conduct by recipients of federal financial assistance. The law has been used in the past to challenge discrimination in health care. The evolution of the health care system from fee-for-service to managed care holds much promise for minority persons, who historically have faced serious, extensively documented barriers to health care access. However, managed care providers, like their fee-for-service counterparts, may perpetuate past discriminatory practices in new ways. Understanding new forms of discrimination is important at this stage of the development of managed care, when program design and policy action can most effectively prevent the occurrence of such practices.
Civil Rights↗
Managed care and people with severe mental illness: challenges and opportunities for social work.
The managed care initiatives sweeping the nation are having a profound effect on the way that social workers deliver services to people with severe mental illness. Social work, with its client-focused value base and relevant conceptual frameworks, has an opportunity to provide leadership in this area. To do so, however, social workers must keep abreast of developments in managed care; use efficacy information more systematically; and promote consumer involvement in the design, implementation, and monitoring of managed care programs for people with severe mental illness.
Delivery of Health Care↗
System change: quality assessment and improvement for Medicaid managed care.
Rising Medicaid health expenditures have hastened the development of State managed care programs. Methods to monitor and improve health care under Medicaid are changing. Under fee-for-service (FFS), the primary concern was to avoid overutilization. Under managed care, it is to avoid underutilization. Quality enhancement thus moves from addressing inefficiency to addressing insufficiency of care. This article presents a case study of Virginia's redesign of Quality Assessment and Improvement (QA/I) for Medicaid, adapting the guidelines of the Quality Assurance Reform Initiative (QARI) of the Health Care Financing Administration (HCFA). The article concludes that redesigns should emphasize Continuous Quality Improvement (CQI) by all providers and of multi-faceted, population-based data.
Guidelines as Topic↗
A new gatekeeper for back pain.
Managed care programs have evolved in response to the escalating costs of healthcare in the United States. Expenses related to back pain represent a significant portion of these costs. Chiropractic physicians handle more back pain visits than do medical doctors and are playing an increasing role in the management of neuromusculoskeletal problems in general. Furthermore, chiropractic patients are more satisfied with their care than are patients of family physicians. A number of studies have shown chiropractic medicine to have high efficacy and cost-effectiveness. Its utilization for neuromusculoskeletal problems in the managed care setting may well offer competitive advantages. Using chiropractic physicians as gatekeepers for back pain would result in more expedient movement through the algorithmic process and facilitate treatment of the patient with acute back pain. Many medical facilities are enhancing their services by utilizing chiropractic physicians as gatekeepers for the diagnosis and treatment of neuromusculoskeletal disorders.
Back Pain↗
Developing effective collaboration between primary care and mental health providers.
OBJECTIVE: Improving care for depressed primary care (PC) patients requires system-level interventions based on chronic illness management with collaboration among primary care providers (PCPs) and mental health providers (MHPs). We describe the development of an effective collaboration system for an ongoing multisite Department of Veterans Affairs (VA) study evaluating a multifaceted program to improve management of major depression in PC practices. METHOD: Translating Initiatives for Depression into Effective Solutions (TIDES) is a research project that helps VA facilities adopt depression care improvements for PC patients with depression. A regional telephone-based depression care management program used Depression Case Managers (DCMs) supervised by MHPs to assist PCPs with patient management. The Collaborative Care Workgroup (CWG) was created to facilitate collaboration between PCPs, MHPs, and DCMs. The CWG used a 3-phase process: (1) identify barriers to better depression treatment, (2) identify target problems and solutions, and (3) institutionalize ongoing problem detection and solution through new policies and procedures. RESULTS: The CWG overcame barriers that exist between PCPs and MHPs, leading to high rates of the following: patients with depression being followed by PCPs (82%), referred PC patients with depression keeping their appointments with MHPs (88%), and PC patients with depression receiving antidepressants (76%). The CWG helped sites implement site-specific protocols for addressing patients with suicidal ideation. CONCLUSION: By applying these steps in PC practices, collaboration between PCPs and MHPs has been improved and maintained. These steps offer a guide to improving collaborative care to manage depression or other chronic disorders within PC clinics.
Journal Article↗
A managed care approach to outpatient review.
The recent growth in outpatient services has been the result of both increased use of new and improved technology, along with a shift to an ambulatory setting for many previously performed inpatient tests and procedures. Employers have seen an almost unchecked rapid growth in this portion of health care costs, with no signs of slowing down. This article attempts to show a basic step-by-step approach to identifying and reviewing some of the major cost generators through a managed care program.
Ambulatory Care↗
Assessing Medicaid recipient access and satisfaction. Fee-for-service, case management, and capitation.
Medicaid increasingly requires enrollment in managed care programs. This study assessed access to care, satisfaction with care, and appointment wait times during the transition from fee for service to managed care using three annual Medicaid recipient surveys. There was little evidence of dissatisfaction or poorer access among managed care recipients. Fee-for-service recipients, compared to primary care case management, reported greater general (91 vs. 78%, p < .01) and specialty care access (92 vs. 80%, p < .01). When appointments were required, adult HMO enrollees, compared to case management, had longer waits for routine care in the second (5.8 +/- 8.2 days vs. 4.0 +/- 6.6) and third surveys (5.5 +/- 6.9 days vs. 3.8 +/- 7.3); waits for other appointments did not consistently differ by program. There were no significant program differences in overall satisfaction. Findings are tempered by the potential for response bias and geographic confounding. Continued monitoring is crucial to assure that access and satisfaction remain high in Medicaid managed care.
Case Management↗
Adoption and implementation of new technologies in substance abuse treatment.
In addition to clinical outcomes, understanding the adoption and implementation of new treatment interventions is essential. This analysis was designed to assess the predictive utility of organization-level features in understanding the adoption and implementation of new technologies in substance abuse treatment. Naltrexone, which was found to be in current use in 44.1% of a national sample of 400 private substance abuse treatment centers, was selected as an appropriate sample technology for study. Adoption of naltrexone is significantly related to both the treatment center's age and its administrative leadership. Naltrexone adoption is also significantly associated with the percentage of the center's caseload covered by managed care programs and by the percentage of relapsers represented in the caseload. The analysis was less successful in predicting naltrexone implementation for either primary alcohol dependence or primary opiate addiction.
Humans↗
Access to and patterns of use of behavioral health services among children and adolescents in TennCare.
OBJECTIVE: This study assessed trends in access to and use of behavioral health services for school-aged children in TennCare, Tennessee's Medicaid managed care program, between state fiscal years 1995 and 2000. METHODS: Claims, encounter, and enrollment data from the Bureau of TennCare were used. The data analyzed were restricted to services and enrollment periods for children and adolescents between the ages of four and 17 years at the time of service or enrollment. Measures were calculated in four areas: overall access to behavioral health services, use of inpatient services, use of outpatient specialty treatment services, and use of supportive services like case management and medication management. RESULTS: The number of youths who received a behavioral service increased by nearly 50 percent between state fiscal years 1995 and 2000. At the same time, the number of youths enrolled in TennCare increased by 19 percent. The annual access rate increased from 72.7 youths per 1000 enrollees to 91.7. However, the volume of services for children fell. Access rates were low relative to estimates of need in this population. The system made less use of inpatient services and relied more on outpatient services, particularly case management and medication management services. CONCLUSIONS: Children's access rates for behavioral health services improved even as the TennCare program expanded to cover more children. The system served more youths in part by reducing the volume of services for children receiving treatment and substituting more supportive services. Ongoing performance monitoring for policy making will require enhancements of data monitoring activities by the state.
Adolescent↗
Pharmacists' role in a smoking-cessation program at a managed health care organization.
A smoking-cessation program at a managed health care organization and the involvement of pharmacists are described. Kaiser Permanente Northwest Region is a prepaid group-practice managed health care organization serving more than 380,000 members in Oregon and southwest Washington. A multidepartmental team at Northwest Region designed and implemented a stepped-care approach to smoking cessation in March 1992. The program progresses from advising and helping patients to quit on their own to enrolling patients in a behavioral-modification course to referring them to nicotine-replacement therapy to be given concurrently with the behavioral modification. The program was established with the help of pharmacists, and pharmacists are deeply involved in its operation. They work closely with each patient, the health educator instructing the patient, and the prescribing physician. Pharmacists attend 5 of the 10 behavioral modification/nicotine-replacement course sessions and take responsibility for enrollees throughout the program. Pharmacists prescribe and monitor nicotine-replacement therapy by protocol. They also monitor each patient for the dose-response effect, adverse drug reactions, drug interactions, concurrent medical conditions, and progress and outcome. The physician is informed about any important changes in the patient's status. In 1992, more than 80 courses were held with nearly 1000 participants, and rates of long-term abstinence achieved compare favorably with literature rates for community-based group smoking-cessation programs. Satisfaction of patients, pharmacists, and physicians with the program has been high. Pharmacists at a managed health care organization participate in a smoking-cessation program by helping with behavioral modification, educating patients about nicotine-replacement therapy, and prescribing and monitoring therapy by protocol.
Behavior Therapy↗
The history and future of cross-cultural psychiatric services.
With cultural issues prominent in the United States today and with ongoing rapid changes in health care management and delivery, this paper discusses the shift from a genetic-type psychiatry (i.e., assuming that humans the world over are no different, and will react to given stressors in life in the same manner) to one recognizing that cultural beliefs, mores, peer pressure, family expectations, and other ingredients operate in unique combinations in various cultures and ethnic groups. These social and cultural factors can and will impact treatment modalities and outcomes. Literature reviewed herein illustrates the progressive stages of awareness and incorporation of cultural differences and the many ways they impact treatment. Unfortunately, the rise in managed, rationed health care threatens the future of this progression. It is essential that culturally-based managed care programs be developed and funded to ensure the availability of cost-effective treatment, through an integrated system of services, to patients of all cultural and economic backgrounds.
Cultural Diversity↗
Health literacy and preventive health care use among Medicare enrollees in a managed care organization.
BACKGROUND: Many older adults in Medicare managed care programs have low health literacy, and this may affect use of preventive services. OBJECTIVES: To determine whether older adults with inadequate health literacy were less likely to report receiving influenza and pneumococcal vaccinations, mammograms, and Papanicolaou smears than individuals with adequate health literacy after adjusting for other covariates. RESEARCH DESIGN: Cross-sectional survey; home interviews with community dwelling enrollees. SUBJECTS: Medicare managed care enrollees 65 to 79 years old in four US cities (n = 2722). MEASURES: Short Test of Functional Health Literacy in Adults and self-reported preventive service use. RESULTS: In bivariate analyses, self-reported lack of preventive services was higher among individuals with inadequate health literacy than those with adequate health literacy: never had an influenza vaccination: 29% versus 19% (P = 0.000); never had a pneumococcal vaccination: 65% versus 54% (P = 0.000); no mammogram in the last 2 years: 24% versus 17% (P = 0.017); never had a Papanicolaou smear: 10% versus 5% (P = 0.002). After adjusting for demographics, years of school completed, income, number of physician visits, and health status, people with inadequate health literacy were more likely to report they had never received the influenza (OR, 1.4; 95% CI, 1.1-1.9) or pneumococcal vaccination (OR, 1.3; 95% CI, 1.1-1.7), and women were less likely to have received a mammogram (OR, 1.5; 95% CI, 1.0-2.2) or Papanicolaou smear (OR, 1.7; 95% CI, 1.0-3.1). CONCLUSIONS: Among Medicare managed care enrollees, inadequate health literacy is independently associated with lower use of preventive health services.
Aged↗