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PubMed1996

Some unchanging values of pediatric education during a time of changing technology and practice.

A few of the opportunities and difficulties of educating pediatric residents in a particular community-based setting, the managed care organization, are discussed in this article. Some of these organizations have deliberately recruited corporate employees with young families, offering relatively complete coverage. Quality problems remain, however. Children may benefit, because managed care arrangements may reduce overdiagnosis and overtreatment, but children may also be deprived, particularly in Medicaid managed care programs, of needed, appropriate care. Pediatric faculties must be confident about the quality of care, the quality of teaching, and the opportunity for residents to develop interpersonal skills before residents are placed in managed care settings. First, however, important, broader aspects of contemporary pediatric education are discussed. These essentials of contemporary pediatric education apply in any setting, community based or not, and not only to physicians in training, but to those who are delivering ongoing care as well. A case study illustrates the impact of technologic advances on medical diagnosis and management. Such advances may lead to the chance for better outcomes but also to confusion, including misperceptions about disease prevalence, the natural history of disease, and therapeutic effectiveness. To meet patient needs and to provide a medically educated physician, the understanding of biology and disease that grows out of scientific advances must be balanced with the illness-related functions of the physician. Two approaches to this goal are suggested: (1) the epidemiologic and demographic anatomy of the health of populations and the socioeconomic kinetics of our society and its diverse value systems relevant to health care should be deliberately structured into all phases of medical education; and (2) the sites of the educational process should be diversified so that residents are placed, perhaps as much as half the time, in those settings in which most patients interact with physicians.

Adolescent↗
PubMed2002

Use of a disease severity index for evaluation of healthcare costs and management of comorbidities of patients with diabetes mellitus.

OBJECTIVES: To evaluate a stratification system for patients with diabetes mellitus according to severity of illness and care requirements and to correlate severity of illness with total medical and pharmaceutical costs of care. STUDY DESIGN, PATIENTS, AND METHODS: A cohort of 697 patients with diabetes mellitus was followed in a diabetes clinic under a managed care plan. Patients were stratified according to severity of illness in 6 clinical areas: glycemic control, cardiovascular disease, peripheral vascular disease/peripheral neuropathy, eye disease, renal disease, and autonomic neuropathy. Stratification was based on clinical elements in patients' medical records related to diabetes mellitus care and its comorbidities. Total medical and pharmaceutical costs were identified for 508 patients who participated in the managed care program for at least 8 months. RESULTS: Patients in high- and very high-risk categories for cardiovascular disease, peripheral vascular disease/peripheral neuropathy, eye disease, and renal disease had markedly increased medical and pharmaceutical costs compared with those in low-risk categories. Pharmaceutical costs for patients in the glycemic control clinical area show a trend toward lower costs at higher risk. Pregnancy and depression were also associated with markedly increased healthcare costs. Patients who were in multiple high- and very high-risk categories had dramatically increased medical costs, as much as 10-fold those of patients who were in none of these categories. CONCLUSIONS: A diabetes mellitus-specific risk stratification system related to required care intensity can be used to identify patients with high medical costs and can enable care providers to select patients for case management and triage into specific care programs.

Adult↗
PubMed1995

Physician participation in Medicaid managed care.

Medicaid programs throughout the United States are moving away from fee-for-service medicine and increasingly towards managed care models in attempts to control rising health care costs. This study examines the participation of physicians in Arizona's prepaid, managed care Medicaid program, the Arizona Health Care Cost Containment System (AHCCCS). In particular, it considers the reasons that physicians decide to participate in AHCCCs, and for participants, the possible impact of these reasons on whether they participate fully or on a limited basis. A mail survey was sent to 300 primary care physicians in Arizona, of which 171 completed surveys were returned. Results suggested that physicians tend to participate because of reimbursement, approval of the 'type' of medicine that managed care allows them to practice, and their belief in Medicaid-type programs. Physician attitudes toward the patients, while generally negative, do not keep them from participating in Medicaid. However, the type of patients in AHCCCS is related to physician satisfaction with the AHCCCS health plans, as is reimbursement. The study indicates differences in the reasons for participation between Arizona's physicians and those in fee-for-service Medicaid programs of other states.

Adult↗
PubMed2001

Comparisons of marriage and family therapists, psychologists, psychiatrists, and social workers on job-related measures and reactions to managed care in Iowa.

This study compares marriage and family therapists (MFTs) to psychologists, psychiatrists, and social workers on job-related measures, such as job autonomy, job satisfaction, burnout, and intention to stay in their present position, as well as on reactions to a managed care initiative in the state of Iowa. Findings indicate that MFTs scored significantly lower than other practitioners on job autonomy and intention to stay in their present position, but there were no differences in job satisfaction or burnout. Marital and family therapists also reported less dissatisfaction with the managed care initiative than psychiatrists, although virtually all practitioners were dissatisfied with the managed-care program. These findings indicate some dissatisfaction within the MFT profession and may be relevant to practitioners seeking to change or expand their practice, as well as to the needs of MFTs in their training programs.

Adult↗
PubMedDate not supplied

Participation of plans and providers in Medicaid and SCHIP managed care. State Children's Health Insurance Program.

For Medicaid and SCHIP managed care programs to succeed, they must attract enough and the right kinds of plans and providers to meet access and care goals. In 2001 we analyzed practices and perceptions that bear on these goals by surveying managed care plans participating in Medicaid or SCHIP, or both, in eleven states. Participating plans appear supportive of both programs and are largely able to secure providers to participate, too. To date, SCHIP has not attracted many plans not already participating in Medicaid. While perceptions were positive in 2001, maintaining current plan and provider relationships in an environment that has become much more budget constrained will be challenging.

Child↗
PubMed1999

Prevention of sexually transmitted diseases. A model for overcoming barriers between managed care and public health. The IOM Workshop on the Role of Health Plans in STD Prevention.

CONTEXT: The growth of managed care has spurred re-evaluation of the roles and responsibilities of public health agencies and private health plans for providing public health services. Although rates of curable sexually transmitted diseases (STDs) in the United States are the highest in the developed world, many clinicians and managed care organizations are not systematically providing high-quality, comprehensive STD-related services to their patients and the community. OBJECTIVE: To examine issues around managed care and STD prevention as a model for overcoming barriers that impede managed care organizations from providing comprehensive public health services and collaborating with health agencies. SETTING: Two-day invitational workshop. PARTICIPANTS: Representatives from 18 health plans, 10 public health agencies, 6 academic institutions, 1 purchasing coalition, and 5 other health organizations. RESULTS: Major obstacles include: turnover and heterogeneity in the health care system; deficiencies in clinical knowledge and skills; differences in organizational culture and language; low priority of STDs; inadequate public health surveillance data and performance measures; confidentiality concerns; and lack of coverage for sex partners. CONCLUSIONS: Potential approaches for addressing these barriers include: requiring that STD-related services be covered by Medicaid managed care programs; implementing performance measures; requiring collaborative activities; promoting education of and outreach to stakeholders; funding of pilot projects; and researching the cost-benefit and cost-effectiveness of STD-related services for various populations.

Communication↗
PubMed1992

Regulating managed care firms: the Connecticut plan.

Virtually every state in the country, as well as the federal government, is either considering or has recently considered legislation to regulate utilization review/managed care companies. Despite the magnitude of this issue, few legislative bodies have expended the resources to study the form that regulation should take. Recently, Connecticut, which has seen considerable growth in utilization review within managed care programs that insure Connecticut residents, funded such a study. This article, authored by two of the study's participants, reviews the issues and explains the study's recommendations.

Attitude of Health Personnel↗
PubMed1991

Savings estimate for a Medicare insured group.

Estimates of the savings potential of a managed-care program for a Medicare retiree population in Michigan under a hypothetical Medicare insured group (MIG) are presented in this article. In return for receiving an experience-rated capitation payment, a MIG would administer all Medicare and employer complementary benefits for its enrollees. A study of the financial and operational feasibility of implementing a MIG for retirees of a national corporation involving an analysis of 1986 claims data finds that selected managed-care initiatives implemented by a MIG would generate an annual savings of 3.8 percent of total (Medicare plus complementary) expenditures. Although savings are less than the 5 percent to be retained by Medicare, this finding illustrates the potential for savings from managed-care initiatives to Medicare generally and to MIGs elsewhere, where savings may be greater if constraints are less restrictive.

Aged↗
PubMed1998

Understanding managed care organizations' liability exposure.

Managed care organizations can minimize their liability exposures by staying informed about industry changes and by implementing a comprehensive risk management program. Typically, managed care organizations face three general exposure areas: directors and officers liability (e.g., exposures associated with nonclinical aspects of an organization); errors and omissions (e.g., exposures involving the day-to-day operations of managing the health care received by an organization's members); and financial loss, or provider excess (e.g., exposures that occur when certain catastrophic events expose the organization to financial peril).

Credentialing↗
PubMedDate not supplied

Demonstrating a positive return on investment for a prenatal program at a managed care organization. An economic analysis.

Healthcare providers need information to guide the management of patient health while administrators focus on resource management. The underpinning of economic analysis, in the clinical setting, is that resources are scarce. The allocation of resources requires delivered services to provide more benefits than cost and hence, the need to demonstrate a return on investment (ROI) for disease management programs. This article describes the ROI for a prenatal program developed at a Western New York Managed Care Organization (MCO). A positive ROI for the program under study will be demonstrated using a model of economic analysis.

Adult↗
PubMed2000

A need for managed care in Saudi Arabia.

Is the Kingdom of Saudi Arabia getting value for money invested in health? Quality care is being provided throughout health facilities in the Kingdom, however there is minimal control of utilization in all health sectors, consequently leading to abuse and over utilization, particularly in the public sector. Managed care programs have proven effective in reducing unnecessary inpatient and ancillary service utilization by reducing use of expensive procedures and unnecessary, highly specialized services, and shifting to less expensive care options. Health maintenance organizations are the best example of a managed health care model; tracking good performance and cost savings averaging between 20-40% compared to more traditional health plans. Key features of health maintenance organizations include serving a defined population voluntarily enrolled in the health plan; assumption of contractual responsibility and financial risk by plan to provide a range of services, and payment of a fixed periodic payment by the enrollee, independent of the actual use of services. The key characteristic that distinguishes health maintenance organizations from other delivery systems is prepayment for the care that is provided. Preferred Provider Organizations offer discounts for services received from a selected set of physicians and hospitals. Services received by enrollees are not fully reimbursed from this selected list of providers. Preferred Provider Organizations use health maintenance organizations administrative processes for controlling costs but do not include some of the intrinsic cost and quality controls of health maintenance organizations. Review of several studies indicate that patients enrolled in prepaid group practices (managed care organizations) were hospitalized 15-40% less often than those enrolled in fee-for-service health plans.

Cost-Benefit Analysis↗
PubMed2002

Setting up a hotline.

Consumer assistance hotlines represent one important model for delivering health-care information to consumers. However, developing and managing such programs can be complicated. This issue brief presents some of the issues involved in setting up and maintaining a hotline. It also highlights the experiences of the Health Rights Hotline, an independent consumer assistance program in Sacramento, California.

Community-Institutional Relations↗
PubMed1996

Managed psychiatric care: a suburban medical department activity model.

Munson Army Community Hospital has successfully realized substantial cost savings by instituting psychiatric managed care. The development of an external partnership with a civilian psychiatric facility is a unique aspect of the psychiatric managed care initiative and has resulted in most of the savings. We staff this partnership hospital with one-half full-time-equivalent psychiatrist. Other psychiatric managed care program elements include: (1) using CHAMPUS "recapture" funds to hire additional personnel; (2) maximizing personnel utilization by combining mental health staff from the social work and psychiatry services; (3) working closely with the community to identify local mental health needs; (4) offering additional therapeutic modalities; and (5) reducing rehospitalization rates through improved discharge planning. We reduced our financial-year first quarter costs by 76% from 1993 to 1995. We attributed much of these savings to reduced residential treatment admissions. Although the total number of outpatient visits increased, Munson's psychiatric services reduced outpatient costs by increasing clinic access. We have used the Gateway to Care program to prepare for the initiation of Tri-Care in our region.

Community Mental Health Services↗
PubMed2003

SSI enrollees' health care in TennCare.

How well does TennCare, Tennessee's Medicaid managed care program, meet the needs of blind/disabled Supplemental Security Income (SSI) enrollees? People with disabilities have extensive health care needs and greater barriers to accessing care, so efforts to reduce service use may decrease their health and independence. On the other hand, managed care plans may better coordinate care. Computer-assisted telephone surveys of urban SSI and other urban TennCare enrollees were conducted to assess these issues. SSI enrollees in TennCare had mixed experiences, and they faced problems in areas particularly important to people with disabilities. Relative to other TennCare enrollees, SSI enrollees had similar or slightly worse access to care and satisfaction. A significant minority of SSI enrollees reported unmet needs for care, such as not getting referrals to specialists, prescription drugs, and special medical equipment. Lack of care coordination was a problem for some SSI enrollees.

Persons with Disabilities↗
PubMed1989

Economy alone is not the answer.

In the absence of quality measures, discounts and utilization controls have been the most visible and easily controlled aspect of the healthcare pricing formula. Now hospitals must begin to demonstrate that their healthcare products provide high quality at a reasonable price. This will be the strongest argument by which hospitals can differentiate themselves and avoid discounting as the sole incentive to shift blocks of patients away from their competitors. By targeting specific payors, hospitals can increase market share through the addition of large pools of prospective patients. This approach is not to be taken as an end to customer-oriented marketing strategies. Instead, it recognizes that the customer will vary from decision to decision. When a managed care program is the customer, value is what the customer wants.

Cost Control↗
PubMed1991

Rollover effects in gatekeeper programs: cushioning the impact of restricted choice.

Public and private medical care plans that restrict the beneficiary's choice of providers have experienced rapid growth in the past decade as a means to contain costs and coordinate care. Such plans have been criticized for engendering beneficiary dissatisfaction and potentially impeding access to necessary care. Some of the objections to primary care "gatekeeping" may be diminished by recruiting the physician who served previously as the beneficiary's "usual source of care" to assume the role of formal gatekeeper. This study examines how persons whose gatekeepers were their regular source of care before plan implementation differed in their use and satisfaction from persons required to change their regular source of care. Our findings indicate that satisfaction was significantly higher among individuals who experienced no change in usual source of care. These individuals also tended to be less likely to use the emergency department as a source of care. Although the data are from Medicaid managed care programs, the findings may also be applicable to private sector point-of-service plans that adopt the primary care gatekeeper model.

Ambulatory Care↗
PubMedDate not supplied

Managed (not to) care: Medicaid and children with disabilities.

The emphasis that managed care programs place on cost containment complicates further the already complex setting for Medicaid health services for children with disabilities by adding an additional barrier to access care to those that already exist. A review considers the attitudes toward and working of Medicaid managed care arrangements for children in general and children with disabilities in particular.

Aid to Families with Dependent Children↗