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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↗
PubMed1997

Cost containment for treating hypertension in African Americans: impact of a combined ACE inhibitor-calcium channel blocker.

The use of calcium channel blockers (CCBs) and angiotensin-converting enzyme (ACE) inhibitors has increased dramatically over the last 10 years and now accounts for 60% to 70% of all new antihypertensive prescriptions. Even though these two classes are efficacious, they are costly. Combined ACE inhibitor/CCB therapy (amlodipine-benazepril) was introduced in 1995. An analysis was done to assess the potential financial impact of substituting this agent for patients being treated with on ACE inhibitor/CCB combination. A pharmaceutical profile review of prescriptions during October 1995 was performed on 219 randomly selected patients enrolled in a Medicaid managed care program. Eighty-four profiles were analyzed; 24% of patients were on a combination ACE inhibitor/CCB regimen with an average monthly cost of $135. If the single agent amlodipine-benazepril with an average monthly cost of $45 (all strengths) was substituted, the savings would be considerable: $1080 per patient per year and $1,080,000 annualized for the calculated number of hypertensives on combination therapy in our network of 15,000 patients. Therapeutic substitution is one method of achieving cost containment in managed care. The cost differential between separately prescribed CCBs and ACE inhibitors and amlodipine-benazepril is significant. Compliance also should be enhanced as the patient would need to take only one pill daily. Once a patient has been maintained on a stable dose of a CCB/ACE inhibitor, substitution with amlodipine-benazepril should be considered.

Amlodipine↗
PubMed1987

The complexities of managed care: operating a voluntary system.

The implementation of state-sponsored voluntary case management programs for public assistance recipients creates provider and recipient recruiting problems that are unique to the state's economic environment, its political climate, its historic relationship with providers, its program goals, and its implementation strategies. This implementation study discusses the factors that influenced the operationalization of the Massachusetts managed care program for AFDC families. The issues of provider recruitment and recipient enrollment are examined in relation to the formal program goals of cost containment and access. The operational and bureaucratic problems the state Medicaid staff has experienced in maintaining the program evokes questions of who should administer the programs, who the best types of providers are in light of program goals, and how recipients can be enrolled in a voluntary program.

Aid to Families with Dependent Children↗
PubMed1998

Managed care, school health programs, and adolescent health services: opportunities for health promotion.

The rapid expansion of managed care creates opportunities and dilemmas for those involved in school health and adolescent health promotion. Managed care organizations (MCOs), public health agencies, and school and adolescent health providers share certain common goals and priorities including an emphasis on prevention, cost-effectiveness, and quality of care--and a willingness to explore innovative approaches to health promotion and disease prevention. However, MCOs often face conflicting challenges, balancing the goals of cost containment and investment in prevention. In considering support for school health programs, MCOs will be interested in evidence about the effectiveness of services in improving health and/or reducing medical expenditures. Mechanisms for improving prevention efforts within MCOs include quality assurance systems to monitor the performance of health plans, practice guidelines from professional organizations, and the contracting process between payers and health care providers. Development of partnerships between MCOs and schools will be a challenge given competing priorities, variation in managed care arrangements, structural differences between MCOs and schools, and variability in services provided by school health programs.

Adolescent↗
PubMedDate not supplied

Issues for patient and family.

This article explores managed care in the 1990s from the perspective of patient and family. This perspective is a complicated one because there is no one managed care program and there is even more diversity among patients and families. Four major issues are singled out for discussion: choice, access, cost, and quality of care. Also discussed are the skills needed by patients and families, as well as health care professionals, that are taking on growing importance in the managed care environment: communication, negotiation, and advocacy.

Costs and Cost Analysis↗
PubMed1993

The changing relationship between clinicians and the laboratory medicine specialist in the managed care era.

Largely because of increased health-care costs, a variety of managed-care programs have been developed, and payment plans based on capitation will probably predominate in the future. Capitated, per-case, or per diem payment plans alter the traditional independence of health-care providers from the payment system. In these systems, clinical laboratory use becomes a resource to be managed, rather than a neutral third party or a source of income. Under capitated payment systems, clinicians will be motivated to reevaluate their own clinical laboratory resource use. Successful laboratory medicine specialists will understand these trends as well as the impact of newer payment plans on the relationship between themselves and clinicians, and develop new strategies to work with clinical colleagues to effect change.

Capitation Fee↗
PubMed1995

Managing change in the era of health reform: organized delivery systems of public health.

As U.S. Medicaid managed care programs proliferate, it appears that traditional clinical training and practice often provide insufficient preparation for physicians to meet the care requirements of Medicaid beneficiaries adequately. State and local health departments have extensive experience with this population's need for preventive care, social support services, care coordination, and referral. Organized delivery systems of managed care can merge the expertise of primary care practitioners, public health professionals, and other community resources to deliver comprehensive care. Although the described model includes Medicaid as the payer, it would remain viable should Medicaid be terminated and universal coverage enacted.

Delivery of Health Care, Integrated↗
PubMed2000

Risk adjusting capitation: applications in employed and disabled populations.

Risk adjustment may be a sensible strategy to reduce selection bias because it links managed care payment directly to the costs of providing services. In this paper we compare risk adjustment models in two populations (public employees and their dependents, and publicly-insured low income individuals with disabilities) in Washington State using two statistical approaches and three health status measures. We conclude that a two-part logistic/GLM statistical model performs better in populations with large numbers of individuals who do not use health services. This model was successfully implemented in the employed population, but the managed care program for the publicly insured population was terminated before risk adjustment could be applied. The choice of the most appropriate health status measure depends on purchasers' principles and desired outcomes.

Adolescent↗
PubMed1996

Pneumocystis pneumonia in a prepaid care system caring for a Medicaid-covered population with AIDS.

Pneumocystis pneumonia (PCP) is the most common pneumonia in persons with acquired immunodeficiency syndrome (AIDS) and a frequent cause of hospitalization. The incidence of PCP in patients with AIDS can be substantially reduced when patients comply with standard prophylaxis protocols. However, achieving acceptable prophylaxis compliance in any patient population is difficult, particularly with intravenous drug users (IVDU), homeless, or medically disenfranchised patients. This study defines the rates and locations of treatment of PCP in a prepaid managed care program for a Medicaid-covered population with AIDS, with comparisons to PCP incidence rates in the same population receiving care in the fee-for-service system.

AIDS-Related Opportunistic Infections↗
PubMed2000

Medicaid managed care in Chicago: changes in utilization.

In 1993, Illinois implemented Healthy Moms/Healthy Kids (HM/HK) in Chicago, a Medicaid managed care program for pregnant women and children. This study examines changes in immunizations for children (n = 134,072), prenatal care use for pregnant women (n = 5,151), and inpatient stays for mothers (n = 5,151) and newborns (n = 2,699) under the HM/HK program as compared with fee-for-service Medicaid in 1992 and 1993. HM/HK children were 10 percent more likely to receive any immunizations, and HM/HK pregnant women were 13 percent more likely to receive some prenatal care. Mothers' inpatient stays at delivery did not change under HM/HK. The length of newborn stays fell between 1992 and 1993, with both the HM/HK and the Medicaid 1993 comparison group deliveries associated with statistically shorter stays. During the early months of the program, improvements in the quantity of expected preventive care received were evident among children and women.

Adult↗
PubMed1991

Union engineers a better health care system.

The Operating Engineers installed a managed care program that focuses on reducing costs by putting controls on key areas like patient length-of-stay and physician unbundling. But it also attempts to maximize quality of care.

Cost Control↗
PubMed2003

Wall Street comes to Washington: where is health care headed?

Although health care spending trends have slowed slightly, employers and consumers can expect another round of double-digit health insurance premium increases in 2004, according to a panel of market and health policy experts at the Center for Studying Health System Change's (HSC) eighth annual Wall Street roundtable. Firms will continue to shift costs to workers but are skeptical of new insurance products, including consumer-driven health plans and tiered provider networks. Most health plans are thriving as they continue to price products ahead of cost trends and gain administrative efficiencies. Many hospitals, facing revenue pressures from increasing competition from physician-owned specialty facilities, are continuing aggressive building campaigns, raising concerns about increased costs if they overshoot and add too much capacity. Efforts to revive the ailing Medicare managed care program face an uphill climb as Congress debates reforms as part of prescription drug legislation.

Economic Competition↗
PubMed2001

Specialists' and primary care physicians' participation in medicaid managed care.

OBJECTIVE: To compare specialist and primary care physician participation in California's Medicaid fee-for-service and managed care programs. DESIGN: Cross-sectional survey. PARTICIPANTS: A probability sample stratified by county and by race of 962 specialist physicians and 713 primary care physicians practicing in the 13 largest counties in California in 1998. MEASUREMENTS AND ANALYSIS: We used physician self-report from mailed questionnaires to compare acceptance of new Medicaid and new Medicaid managed care patients by specialists versus primary care physicians and by physician demographics, practice setting, attitudes toward Medicaid patients, and attitudes toward Medicaid managed care. We analyzed results using logistic regression with data weighted to represent the total population of primary care and specialist physicians in the 13 counties. MAIN RESULTS: Specialists were as likely as primary care physicians to have any Medicaid patients in their practices (56% vs 56%; P=.9). Among physicians accepting any new patients, specialists were more likely than primary care physicians to be taking new Medicaid patients but were significantly more likely to limit their acceptance to only Medicaid fee-for-service patients. Thus, specialists were much less likely than primary care physicians to accept new Medicaid managed care patients. After controlling for physician demographics, practice settings, and attitudes toward Medicaid patients and Medicaid managed care, specialists remained much less likely to accept new Medicaid managed care patients. CONCLUSIONS: Expansion of Medicaid managed care may decrease access to specialists as specialists were less likely to accept new Medicaid managed care patients compared to Medicaid fee-for-service patients. Any decrease in access may be mitigated if states are able to contract with group model HMOs and to recruit minority physicians.

Adult↗
PubMed1996

A review of dental HMO expenses: where do the dental premium dollars really go?

The savings and profits that managed care programs have realized in medical care have prodded managed care companies to look at dentistry for similar results. In this article, the authors evaluate the impact of various dental managed care plans by examining how they allocate premium dollars. Dentists and purchasers need this information to assure themselves that the plans allocate adequate dollars for the provision of care and that the premium dollars paid are used effectively and efficiently.

Efficiency, Organizational↗
PubMedDate not supplied

Designing an integrated drug benefit for the elderly.

The elderly are hit hard by high out-of-pocket expenses for medicines, but a stand-alone pharmaceutical benefit could cost the country billions and still not improve older Americans' quality of care. Such a benefit should be coordinated with patients' overall medical benefits. A systems-based pharmaceutical benefit is financially feasible through a combination of premiums and cost sharing, market-driven price reductions, and cost savings achieved through integrated managed care programs and improved outcomes.

Aged↗
PubMed2003

Prenatal psychosocial needs: differences between a TennCare group and a privately insured group in Appalachia.

The purpose of this study was to determine the prenatal psychosocial needs of a group of women enrolled in TennCare, a Medicaid managed care program designed to cover all otherwise uninsured people in Tennessee, and compare them with privately insured women. Face-to-face interviews were conducted using standard and reliable questionnaires with a convenience sample of 120 pregnant women between 14 and 44 years of age and 16 to 28 weeks gestation at three prenatal clinics in East Tennessee. Chi-square analysis revealed that the TennCare enrollees in East Tennessee were significantly more likely to report higher psychosocial needs in pregnancy than the privately insured group. Women enrolled in TennCare had a significantly higher incidence of physical abuse, depressive symptoms, and smoking than the privately insured group. Pregnancy provides a window of opportunity for assessing and intervening with vulnerable women enrolled in Medicaid managed care who report psychosocial problems.

Adolescent↗