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Core services and priority-setting: the New Zealand experience.

Like people in other countries, New Zealanders have been struggling with the issue of how to decide which health services should be delivered and to whom. The government has established a Core Services Committee to advise on core services, that is, those health care and disability support services to be made available on affordable terms and without unreasonable waiting time. Such a core has a similar role to a standard package of benefits within a managed competition framework. Services not in the core would be left to individuals' own responsibility. Specific objectives for a core are to promote accountability of purchasers, to make explicit the services that are core and those that are not, to promote an efficient and equitable allocation of resources, to limit government expenditure on health care and to involve the public in decision-making. A number of different options for defining a core are identified, and the work undertaken so far is discussed. The original concept of a core has not been implemented in New Zealand. The Core Services Committee has established broad priorities and facilitated a series of consensus development conferences to provide advice on the effectiveness of services. Some of the committee's recommendations have been incorporated into policy guidelines, which set out what the government expects of purchasers. These guidelines include priority areas for health gains, service obligations and principles for purchasing. Service obligations are not sufficiently detailed to meet the specific objectives of a core and do not meet equity objectives, as they allow in effect each of the four purchasers to develop their own core of services. The key issue for the government now is to decide whether to allow RHAs flexibility in determining their own priorities or whether a national approach to efficiency and equity is to be preferred.

Competitive Medical Plans↗

Clinton's health plan: Prudential's choice.

President Clinton has proposed a managed competition model for health care reform. This strategy would accelerate the corporatization of U.S. health care resulting in more bureaucracy, less patient choice, and a health system owned by a few insurance giants. There is no evidence that competition or other central features of Clinton's plan can lower costs or improve quality. Because cost containment is doubtful, the promised expansion of coverage is unlikely to be implemented.

Competitive Medical Plans↗

Managed care.

Health-care reform has become a national mandate. Managed care and managed competition have been reinforced by the Clinton health-care reform plan. What type of health-care delivery system can laboratory managers expect to be part of in the near future? We asked laboratory managers who are currently involved in those types of systems. The result is a two-part As We See It. In part one, we will cover physician partnerships and the system laboratory as we ask: What can the laboratory community expect from a managed-care environment?

Administrative Personnel↗

The effects of hospital-physician integration strategies on hospital financial performance.

STUDY QUESTION: This study investigated the longitudinal relations between hospital financial performance outcomes and three hospital-physician integration strategies: physician involvement in hospital governance, hospital ownership by physicians, and the integration of hospital-physician financial relationships. DATA SOURCES AND STUDY SETTING: Using secondary data from the State of California, integration strategies in approximately 300 California short-term acute care hospitals were tracked over a ten-year period (1981-1990). STUDY DESIGN: The study used an archival design. Hospital performance was measured on three dimensions: operational profitability, occupancy, and costs. Thirteen control variables were used in the analyses: market competition, affluence, and rurality; hospital ownership; teaching costs and intensity; multihospital system membership; hospital size; outpatient service mix; patient volume case mix; Medicare and Medicaid intensity; and managed care intensity. DATA COLLECTION/EXTRACTION: Financial and utilization data were obtained from the State of California, which requires annual hospital reports. A series of longitudinal regressions tested the hypotheses. PRINCIPAL FINDINGS: Considerable variation was found in the popularity of the three strategies and their ability to predict hospital performance outcomes. Physician involvement in hospital governance increased modestly from 1981-1990, while ownership and financial integration declined significantly. Physician governance was associated with greater occupancy and higher operating margins, while financial integration was related to lower hospital operating costs. Direct physician ownership, particularly in small hospitals, was associated with lower operating margins and higher costs. Subsample analyses indicate that implementation of the Medicare prospective payment system in 1983 had a major impact on these relationships, especially on the benefits of financial integration. CONCLUSIONS: The findings support the validity of hospital-physician financial integration efforts, and to a lesser extent the involvement of physicians in hospital governance. The results lend considerably less support for strategies built around direct physician ownership in hospitals, particularly since PPS implementation. RELEVANCE/IMPACT: These findings challenge prior studies that found few financial benefits to hospital-physician integration prior to PPS implementation in 1983. The results imply that financial benefits of integration may take several years after implementation to emerge, are most salient in a managed care or managed competition environment, and vary by hospital size and multihospital system membership.

Analysis of Variance↗

Canaries in a coal mine: California physician groups and competition.

Health care organizations may compete by developing organized processes to improve quality and increase efficiency, or may focus on growing to increase negotiating leverage and on controlling costs through withholding appropriate care and avoiding sick patients. This paper describes key ways in which public and private policy decisions create incentives that influence the competitive focus of physician groups in California, a state in which physician groups and health maintenance organizations are prevalent. These policies do not manage competition in optimal ways: They reward groups for market leverage and controlling costs while failing to fully reward quality and efficiency.

California↗

Competition on quality in managed care.

There is intense competition between managed care organizations (MCOs) in the USA based on cost and benefit coverage, but scant attention to differences in quality. Consumer preference for 'choice' has stimulated the growth of overlapping networks of providers across competing MCOs. These networks have tended to perform less well on the quality indicators in report cards than staff model MCOs. Ideally one would measure individual provider performance; but the overlapping networks, and the fact that each MCO represents a small fraction of each provider's practice, make that difficult to do. MCOs could potentially collaborate to measure individual provider performance. Financial incentives and risk-adjusted premiums might stimulate competition on quality within MCOs. It seems more likely that true competition on quality will occur between groups of providers, organized or integrated delivery systems, than between MCOs. Nevertheless, MCOs are likely to offer some quality-improving programs directly to their members, and can stimulate the competition between providers by collaborating to obtain provider-specific measurements.

Consumer Behavior↗

Ethical questions under managed care begin to surface in the literature.

Defining the specific ethical issues anticipated under integrated health care delivery systems is difficult for several reasons: (1) We don't know with certainty what structures, processes, and rules will be in place, and (2) the lines of authority and accountability are still unsettled. Despite these unknowns, everyone seems fairly certain that managed care processes within a structure of managed competition will be permanent and prominent fixtures in the reformed environment of health care. The following articles summarize three recent articles on life under managed care. The first two reflect the concerns of physician-ethicists, and the third makes an effort to think of ethical obligations at the organizational level.

Ethics, Medical↗

Washington mulls over managed-care reform options.

April 24, 1994, 10:35 a.m., EST ... the fateful moment when healthcare spending in America is predicted to reach the unbelievable $1 trillion mark. Managed care--or some version of the much-touted managed-competition proposal--is likely to be a part of cost-saving plans now spinning out of the beltway. Open systems governed by standards are the technological bywords of the future.

Competitive Medical Plans↗

Home care networks, alliances, & acquisitions.

Experts indicate that managed competition will be a factor in reformed health care delivery. In such an environment agencies need to strengthen their financial bases, possibly by connecting with other providers, and numerous legal questions can arise.

Capital Financing↗

Health care reform starts with primary care.

Under the Clinton health care reform plan, primary care physicians will be the gatekeepers of the health care system. Patrick E. Kapsner, FACMPE, writes about how the primary care physician will be a part of managed competition and how they will interrelate with specialty practices.

Group Practice, Prepaid↗

Reproductive health practices of HMOs serving urban low-income women.

As managed competition expands, many health plans wish to open their membership to those on Medicaid, mostly women and children. This study examines the reproductive services of 10 diverse managed care organizations historically targeting large numbers of poor women for care through prepaid Medicaid contracts. These institutions think themselves united and unique within managed care because of their long-term commitment to serving patients on Medicaid. Although the interviews with providers and administrators explore many aspects of reproductive care, most of these health maintenance organizations (HMOs), by the nature of their funding and federal mandates, have more aggressive and defined programs for pregnant women and for infants. These urban-based providers have discovered by trial and error the challenges of getting quality health care to poor women: external administrative or bureaucratic challenges because of Medicaid, internal administrative or provider barriers, and the artifacts of patient behavior. Strategies to address these problems involve attending to political and bureaucratic factors affecting care, taking a broader social view of patients and their community, using community resources to supplement HMO benefits, maximizing each contact with patients with multiple interventions, case management to monitor underutilization, aggressive outreach, service, and follow-up.

Female↗

[Managed health care--second opinion from the viewpoint of Swiss orthopedists].

Health Care reform rapidly changes the US health system and enters our "free system" with various aspects. The understanding of the buzzwords in managed care and the so-called managed competition are the context for making informed decisions about our future. We must develop at least a rudimentary understanding of the ways many types of collaborative efforts and managed care organisations evolve. We must know to ask the right questions and hopefully find the correct answers for the benefit of our patient.

Cost Control↗

Health care reform and people with disabilities.

As a group, people with disabilities or chronic conditions experience higher-than-average health care costs and have difficulty gaining access to affordable private health insurance coverage. While the Americans with Disabilities Act will enhance access by prohibiting differential treatment without sound actuarial justification, it will not guarantee equal access for people in impairment groups with high utilization rates. Health care reform is needed to subsidize the coverage of such individuals. Such subsidization can be achieved under either a casualty insurance model, in which premiums based on expected costs are subsidized directly, or a social insurance model, in which low-cost enrollees cross-subsidize high-cost enrollees. Cost containment provisions that focus on the provider, such as global budgeting and managed competition, will adversely affect disabled people if providers do not have adequate incentives to meet these people's needs. Provisions focusing on the consumer, such as cost sharing, case management, and benefit reductions, will adversely affect disabled people if they unduly limit needed services or impose a disproportionate financial burden on disabled people.

Adolescent↗

Parental Optimism and Progeny Choice: When is Screening for Offspring Quality Affordable.

Three general classes of fitness incentives have been proposed for parental overproduction of offspring: (1) tracking environmental variation; (2) developmental facilitation; and (3) replacements for failed or defective members of the core brood. In one version of this last category, called the progeny choice hypothesis, parents are seen as creating an enlarged array of offspring from which a genetically superior subset is chosen for full investment. In the selection process, parents may eliminate the victims either through personal effort (filial infanticide) or by proxy (by allowing or even encouraging fatal sibling rivalry). Because the culling process is non-random, it can elevate average offspring quality. Progeny choice, however, is only cost-effective if the expenses of early overproduction (including elevated levels of sibling competition) do not outweigh the eventual upgrade in offspring quality. A fair competition within the offspring "arena" offers the greatest potential for discriminating on the basis of intrinsic quality, but may be overwhelmed by high costs of sibling rivalry. Conversely, while parentally managed competition (conferring handicaps to some and advantages to others) can discount those rivalry costs, it simultaneously diminishes the system's capacity for distinguishing good offspring from bad. Ceteris paribus, one would expect to find progeny choice mechanisms in species with cheap sibling rivalry, large cohorts of evenly matched offspring, and exaggerated variation in offspring genetic quality. Conversely, this class of incentives of parental overproduction seems least suited to taxa in which parents dole out marked advantages or handicaps to various concurrent offspring (e.g. asynchronously hatching birds).Copyright 1998 Academic Press Limited

Journal Article↗

Market reform and universal coverage: avoid market failure.

Determining the marketing mix for hospitals, especially those in transition, will require critical analysis to guard against market failure. Managed competition requires careful planning and awareness of pricing components in a free-market situation. Alain Enthoven, writing for the Jackson Hole Group, proposes establishment of a new national system of sponsor organizations--Health Insurance Purchasing Cooperatives--to function as a collective purchasing agent on behalf of small employers and individuals.

Commerce↗

Alternatives to Federal regulatory realignment of health care.

In this article, author Christopher J. Kalkhof puts forth the view that the U.S. healthcare system could be made more cost effective and cost efficient without the implementation of government-directed managed competition strategies. Noting that current private sector initiatives already are forming more cost-sensitive integrated delivery and financing mechanisms, Kalkhof asserts that corresponding realignment initiatives for publicly financed healthcare benefit programs would provide additional incentive and momentum for these private sector efforts without requiring reconfiguration of the healthcare system by the government.

Competitive Medical Plans↗