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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↗
PubMed2001

A statewide assessment of lead screening histories of preschool children enrolled in a Medicaid managed care program.

OBJECTIVES: Despite the prominence of lead poisoning as a public health problem, recent Government Accounting Office reports indicate that only one fifth of children who are covered by Medicaid have been screened for lead poisoning. The purpose of this study was to examine the lead screening histories of children who were enrolled in a statewide, Medicaid managed care plan to determine the relative impact of the type of primary care provider site and family sociodemographic characteristics on the likelihood of being screened. The study also examined the prevalence of and risk factors for lead poisoning of children who had been screened. METHODS: A random sample of 2000 preschool-age children was chosen from those who were enrolled continuously in the statewide, expanded, Medicaid managed care program for a 1-year period and between the ages of 19 and 35 months at the end of that year. Sociodemographic characteristics and lists of primary care providers were obtained from administrative data sets. Medical record audits at primary care provider sites were performed to obtain the lead screening histories of the children, including test dates and results. RESULTS: Data on 1988 children were used for study analyses, and 80% of these children had at least 1 documented blood lead level. Children whose primary care provider was an office-based physician were less likely to be screened as compared with patients of health centers, hospital-based clinics, and staff model health maintenance organizations (68%, 86%, 89%, and 91% respectively). Variation in screening rates persisted in a multivariate analysis controlling for family sociodemographic characteristics and practice level variation. Of the 1587 children who had a documented blood lead test, 467 children (29%) had a blood lead level of >/=10 mg/dL on at least 1 test. CONCLUSIONS: Blood lead screening rates in Rhode Island's Medicaid managed care program are dramatically higher than national estimates for children who are enrolled in Medicaid. Potential explanations for this finding are 1) a high sensitization to the problem of lead poisoning in Rhode Island, 2) the primary care focus of the Medicaid program in Rhode Island facilitates the delivery of preventive services, and 3) the medical record audit approach used in this study was more comprehensive in identifying blood lead screens than techniques used in national studies. The high prevalence of elevated blood lead levels found in this study emphasizes the importance of screening among children who are enrolled in Medicaid.

Child, Preschool↗
PubMed2000

A survey of participation in managed care programs by endodontic specialists.

A survey was published in the Quarterly Survey of Dental Practice (QSDP) Special Topics that dealt with contractual agreements in dentistry. This survey evaluated general dental practitioner participation apart from that of dental specialists in general. The Quarterly Survey of Dental Practice survey was modified and used in the present study to specifically determine the participation by endodontists in various contractual insurance agreements, including Preferred Provider Organization and Health Maintenance Organization programs. A 10% sample of practicing endodontists was randomly selected to participate in this survey. Questionnaires (331) were sent out, and 229 or 69% were returned. Total participation by endodontists responding to this survey in any Health Maintenance Organization and/or Preferred Provider Organization insurance plans was 31.3%; however the total percentage of patients treated under these insurance plans was only 6.6%. These results were similar to those in the 1994 survey in which it was shown that 27% of the general dental practitioners and 41% of the dental specialists participated in one or more of these insurance programs and treated respectively, 5% and 9%, of their patients under these plans. Although participation in various managed care programs by endodontists in this survey was close to one-third, the total number of patients treated under these plans was low. Overall patients treated under fee-for-service arrangements by endodontists responding to this survey formed 85.3% of their patient pool. It does not appear from the results of this survey that managed care insurance has a significant impact on the practice of endodontics. It can be postulated that endodontists are unwilling to accept more than a small reduction in fees to join managed care plans, and they also desire to retain full control of their dental practice.

Analysis of Variance↗
PubMed1990

Managed care programs.

Explore the source record for details and available documents.

Health Maintenance Organizations↗
PubMed2001

The development of a palliative care program for managed care patients: a case example.

Palliative care is emerging as an important new field. Although programs are developing in hospital environments, little is known about development of programs in outpatient practices or those serving large managed care populations. This article provides a framework for the development of a comprehensive palliative care program in a large multispecialty group practice that serves managed care patients. The article addresses guiding principles, the need for obtaining baseline data, how the clinical consultation service was established, development of outcomes measures, and information on current program status. Five themes emerged as key to successful program development, most importantly the close collaboration between administrative and clinical staff in all aspects of program development.

Aged↗
PubMed1997

Physician participation in a Medicaid managed care program, the Kansas Primary Care Network.

This study was designed to identify the factors that enhance and impede physician participation in a Medicaid managed care program, the Kansas Primary Care Network (PCN). The data for the study were collected in the summer of 1993 through a mail survey of primary care physicians in the PCN service area. Logistic regression and cross tabular analytic techniques were employed for data analysis. The results indicate that physicians who are not receptive to capitation-based reimbursement practices, those who practice in the higher per capita income counties, those who do not compare the PCN reimbursement rates favorably with private insurance rates, and physicians who think that untimely payment and the requirement to document patient referrals for specialty treatment pose problems for them are less likely to participate in the PCN program. Further, the study shows that institutional physicians have larger Medicaid caseloads than solo practitioners, who have larger Medicaid caseloads than single-specialty and multi-specialty group practitioners. Since most of the variables that attain statistical significance in explaining physician participation in the PCN program have to do with money, the study reaffirms the two market theory of the United States' health care delivery system.

Attitude of Health Personnel↗
PubMed1999

The effect of a Medicaid managed care program on the adequacy of prenatal care utilization in Rhode Island.

OBJECTIVES: The purpose of this study was to determine whether adequacy of prenatal care utilization improved after the implementation of a Medicaid managed care program in Rhode Island. METHODS: Rhode Island birth certificate data (1993-1995; n = 37021) were used to analyze pre- and post-program implementation changes in adequacy of prenatal care utilization. Logistic regression models were used to characterize the variation in prenatal care adequacy as a function of both time and the various covariates. RESULTS: Adequacy of prenatal care utilization for Medicaid patients improved significantly after implementation of the program, from 57.1% to 62.1% (odds ratio [OR] = 1.2, 95% confidence interval [CI] = 1.1, 1.3). After the program was implemented, Medicaid patients who went to private physicians' offices for prenatal care were 1.4 times as likely as before to receive adequate prenatal care (OR = 1.4, 95% CI = 1.2, 1.7). CONCLUSIONS: Unlike many other Medicaid expansions for pregnant women, the RIte Care program in Rhode Island has resulted in significant improvement in adequacy of prenatal care utilization for its enrollees. This improvement was due to specific program interventions that addressed and changed organizational and delivery system barriers to care.

Adolescent↗
PubMedDate not supplied

Quality care in a medicaid managed care program: adequacy of prenatal care for teens in Chicago.

This study considers whether obstetricians offer less adequate care to teen prenatal patients in the Healthy Moms, Healthy Kids (HMHK) Medicaid managed care program in Chicago than to non-Medicaid patients. Telephone surveys of obstetricians offices (n = 101) were conducted to determine the content of care in the first prenatal visit. These survey data are combined with demographic and practice background data from The American Medical Association's Physician Master File. Analysis indicates there were no significant differences between groups for receiving: (1) medical histories, (2) physical exam and tests, (3) health promotion counseling, and (4) availability of birthing education materials. Analysis further indicates, however, that teen Medicaid patients are less likely to receive blood tests and some urinalysis-related tests. Not receiving these tests is especially problematic because pregnant teens are more likely to drop out of the prenatal care regimen after their first visit, and teens are more likely to have poorer birth outcomes.

Adolescent↗
PubMed1999

A comparison study of access to health care under a Medicaid managed care program.

This article investigates the health care and insurance status of a low-income urban area in East Tennessee. The article reviews the background of TennCare, a compulsory Medicaid managed care program initiated in Tennessee in 1994. The study compared TennCare recipients with other insurance groups on key demographic and access variables. Possible explanations for how TennCare recipients rate their care also were examined. Qualitative analysis revealed accounts of long waiting periods, out-of-town specialist care, problems with obtaining pharmaceuticals, and general confusion about the new system. Implications of these findings for social work policy practitioners are discussed, and suggestions for alleviating the burden on patients are offered.

Adult↗
PubMedDate not supplied

[A proposed open formulary for a managed care program in Mexico. The Therapeutic and Pharmacological Committee of Mexico].

OBJECTIVE: To integrate an open formulary with drug use recommendations in which a physician could find a wide range of therapeutic options for his private practice. MATERIAL AND METHODS: An interdisciplinary medical committee with a high scientific level, reviewed each one of all the drugs available to be sell in Mexico, as part of a Pharmacy Benefit Management & Manage Care program implemented in our country. Each drug was classified according to its active ingredient under one of the following categories: 1) essentials, 2) excluded, and 3) not essentials-not excluded. The decision in each case was based on pure scientific grounds and using an Evidence-Based Medicine analysis. RESULTS: The proposed formulary contains a total of 1106 active ingredients-either unique or in combination-, from which 429 (38.8%) were classified as essentials. About one-out-of-ten drugs (8.7%) currently in use within the private medical practice in Mexico, some of them highly prescribed, were regarded by the committee as excluded due to concerns about their efficacy and/or safety. CONCLUSIONS: On this report a detailed description of the process followed to conform the committee, its objectives an its performing criteria is presented, as well as the bases under which the final list of drugs of the formulary were set.

Formularies as Topic↗