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PubMed2001

Mediating denials of pharmaceutical services: an alternative to traditional appeals.

The effectiveness of mediation as a primary tool to resolve pharmaceutical service denials by managed care is discussed. A three-month prospective randomized trial of 48 medical appeal cases involving prescription drugs was conducted by Tennessee's Department of Health. Patients whose prescription claims were denied by the state's Medicaid managed care program and whose appeals were deemed medically unnecessary by one of two independent reviewers were randomly assigned to either a standard procedure group or a mediation group. Appeals assigned to the standard procedure group were immediately referred for administrative hearing. In the mediation group, the independent reviewer assigned to the case contacted the patient's care provider, discussed the case, and recommended an alternative drug. The care provider either accepted the suggested compromise, concluding the appeals process, or declined the suggestion, allowing the appeal to go to hearing. Reviewers recorded the amount of time they spent on each appeal. The mediation did not substantially increase the time the reviewers spent on each case (mean +/- S.D. minutes, 15.83+/-7.89 mediation versus 12.26+/-6.96 standard procedure). The mean number of appealed drugs was also similar between groups (1.46+/-0.78 mediation versus 1.35+/-0.89 standard procedure). Only 21% of appealed cases went to hearings in the mediation group, while 80% did in the standard procedure group. The average cost to the state for employing mediation ($142.92+/-$186.77) was significantly lower than the average cost incurred by using standard procedures ($355.75+/-$175.43). Mediation is an effective and efficient tool for resolving patients' appeals of denied pharmaceutical services.

Drug Prescriptions↗
PubMed2002

Changes in antibiotic prescribing for children after a community-wide campaign.

CONTEXT: Overuse of antibiotics has contributed to microbial resistance, compromising the treatment of bacterial infections. Very high levels (>50%) of antibiotic resistance among invasive Streptococcus pneumoniae have been documented in Knox County, Tennessee. OBJECTIVE: To determine the effectiveness of a community-wide intervention aimed at reducing inappropriate antibiotic use among children. DESIGN, SETTING, AND PARTICIPANTS: The Knox County Health Department led a multifaceted year-long campaign (May 1997 through April 1998) aimed at decreasing unnecessary antibiotic use among children. Tennessee's 3 other major urban counties (Shelby, Hamilton, and Davidson) did not conduct similar campaigns and served as controls. Evaluation included white and black children (aged <15 years) enrolled in Tennessee's Medicaid Managed Care Program in the 4 study counties, representing 36% of the study counties' children (464 200 person-years observed). INTERVENTION: Educational efforts were directed toward health care practitioners (primarily via peer leader presentations) and to the parents of young children and the public (primarily via printed materials). MAIN OUTCOME MEASURE: The intervention-attributable effect on antibiotic use, defined as the excess percentage change in oral antibiotic prescription rates in Knox County between the 12-month preintervention and postintervention periods, relative to that of control counties. RESULTS: Antibiotic prescription rates declined 19% and 8% among Knox County and control county children, respectively, yielding an 11% intervention-attributable decline (95% confidence interval, 8%-14%; P<.001). The intervention-attributable decrease in prescription rates was greatest among children aged 1 to less than 5 years (among white children, 8% [P<.001]; among black children, 18% [P<.001]). CONCLUSIONS: A community-wide educational intervention reduced antibiotic prescription levels among children in Knox County.

Adolescent↗
PubMed2004

Isolating the effect of alcoholism treatment on medical care use.

OBJECTIVE: This study seeks to refine the analysis of the effects of alcoholism treatment on subsequent use of medical care by examining components of the latter. METHOD: Claims and encounter data of 29,122 adults (mean age 40, 35% female) receiving benefits from both a mental health managed care program and its parent medical care insurance company who had a diagnosis of alcoholism were analyzed using a longitudinal Poisson regression model fit by the generalized estimating equation method to compare differences between the groups in medical utilization before and after alcoholism treatment. The diagnoses associated with medical care were assigned to one of four groups: alcohol specific, alcohol acute, alcohol chronic and nonalcohol related. All persons applying for alcoholism treatment benefits were included; those who had fewer than four visits for alcoholism treatment served as controls. RESULTS: The largest effect of alcoholism treatment is seen for medical encounters associated with diagnoses that reflect the acute effects of intoxication. The frequency of encounters related to conditions associated with chronic alcohol misuse were the only type that did not significantly decline 1 year past treatment in the outpatient treatment group. CONCLUSIONS: This study provides support for the belief that treatment for alcoholism is directly associated with a change in medical care use. However, the findings suggest that the impact on utilization varies with the type of medical care. The most pronounced effects appear to be for acute problems that may be most directly attributed to the effects of active drinking. Changes in medical utilization in this area, therefore, may be responsible for the cost-offset of alcoholism treatment that has been observed in prior research.

Adult↗
PubMed2003

The effect of Evercare on hospital use.

OBJECTIVES: To examine the use of hospital and related medical care services of a novel managed care program using nurse practitioners (NPs) and directed specifically at long-stay nursing home residents. DESIGN: Quasi-experimental posttest design with two control groups to minimize selection bias. SETTING: Nursing homes. PARTICIPANTS: Evercare enrollees in five sites were compared with two sets of controls: nursing home residents in the same nursing homes who did not enroll in Evercare (control-in) and residents of nursing homes that did not participate in Evercare (control-out). MEASUREMENTS: Utilization data from Medicare and United Healthcare (the parent corporation for Evercare) were obtained for slightly more than 2 years. Patterns of use were assessed by calculating the monthly use rate for each group and aggregating to form annual rates. Usages addressed included hospital admissions and days, emergency room visits, therapy services, mental health services, and podiatry. Adjustments were made to correct for age, race, and sex. Because the groups differed in terms of the rate of cognitive impairment, the analysis was stratified on this variable. RESULTS: The incidence of hospitalizations was twice as high in control residents as in Evercare residents (4.63 and 4.67 per 100 enrollees per month vs 2.43 in the 15 months after census, P<.001). This difference corresponded to Evercare's use of intensive service days. The same pattern held for preventable hospitalizations (0.80 and 0.86 vs 0.28, P<.001). The pattern held when residents were stratified by cognitive status. On average, using a NP is estimated to save about $103,000 a year in hospital costs per NP. CONCLUSION: The use of active primary care provided by NPs may have prevented the occurrence of some hospitalizable events, but its major effect was allowing cases to be managed more cost-effectively.

Aged↗
PubMed2003

Outcomes of managed care of dually eligible older persons.

PURPOSE: To assess changes in various functional and satisfaction measures between older persons enrolled in Minnesota Senior Health Options (MSHO), a managed care program for older persons eligible for both Medicare and Medicaid. DESIGN AND METHODS: We used two sets of matched controls for MSHO enrollees and their families and matched controls living in the community and in nursing homes: Persons in the same county who were eligible to enroll but did not enroll in MSHO and persons in other metropolitan areas where MSHO is not available. For the community sample, we used questionnaires to measure functional status (activities of daily living), pain, unmet care needs, satisfaction, and caregiver burden. Approximately 2 years after the first survey, we resurveyed respondents who lived in the community at the time of the first survey. For the nursing home residents, we used annual assessments to calculate case mix to compare changes in functional levels over time. RESULTS: There were few significant differences in change over time between the MSHO sample and the two control groups. Out-of-area controls showed greater increases in pain but in-area controls showed less interference from pain. Compared with out-of-area controls, MSHO clients showed greater increase in homemaker use, meals on wheels, and outpatient rehabilitation. Compared with in-area controls, they showed more use of meals on wheels and less help from family with household tasks. There were few differences in satisfaction, but the MSHO families showed significantly lower burden than controls on five items. IMPLICATIONS: The analyses show only modest evidence of benefit from MSHO compared with the two control groups. The model represented by MSHO does not appear to generate substantial differences in outcomes across function, satisfaction, and caregiver burden.

Aging↗
PubMed2004

Predictors of children's healthcare use: the value of child versus parental perspectives on healthcare needs.

OBJECTIVE: The objective of this study was to examine the relationship between healthcare use and children's healthcare needs as assessed from the perspectives of children themselves, parents, and healthcare practitioners. RESEARCH DESIGN: We conducted a prospective cohort study in which service use was monitored for the 12 months before and after administration of a health survey. SUBJECTS: We studied 384 parents and children aged 6 to 11 years enrolled for 2 years in a northern California health maintenance organization or a Medicaid managed care program in Rhode Island. MEASURES: Child and parent perspectives on needs were determined using the Child Health and Illness Profile, Child Edition (CHIP-CE). Plan administrative data were used to develop a treated morbidity index, which was based on diagnosis codes recorded by practitioners during the year before the survey and to obtain prospective measures of service use. RESULTS: For both child- and parent-respondents, low satisfaction and comfort scale scores from the CHIP-CE were significant predictors of number of visits. CHIP-CE domain scales unrelated to future use were risk avoidance, resilience, and achievement. Multivariable regression using CHIP-CE information collected from children explained more variation in total physician visits than models that used parent-respondent data. The treated morbidity index was a weaker predictor of physician visits than the CHIP-CE scale scores. None of the domain scales were significant predictors of any emergency department use or any specialist use; however, the treated morbidity index was associated with any specialist use. CONCLUSIONS: A child's sense of well-being and burden of symptoms predict future use. Perceived healthcare needs, as assessed by the CHIP-CE, is a better predictor of children's service use than evaluated needs as assessed by physician-diagnosed disorders. Our results support the validity of using the responses of children aged 6 to 11 years as a measure of need for future health care.

Adaptation, Psychological↗
PubMed2006

Relationship between quality of care and racial disparities in Medicare health plans.

CONTEXT: Overall quality of care and racial disparities in quality are important and related problems in health care, but their relationship has not been well studied. In the Medicare managed care program, broad improvements in quality have been accompanied by reduced racial gaps in processes of care, but substantial disparities in outcomes have persisted. OBJECTIVES: To assess variations among Medicare health plans in overall quality and racial disparity in 4 Health Plan Employer and Data Information Set (HEDIS) outcome measures, to determine whether high-performing plans exhibit smaller racial disparities, and to identify plans with high quality and low disparity. DESIGN, SETTING, AND PATIENTS: We assessed the relationship between quality and racial disparity using multilevel multivariable regression models. The study sample included 431,573 individual-level observations in 151 Medicare health plans from 2002 to 2004. MAIN OUTCOME MEASURES: Hemoglobin A(1c) of less than 9.5% or less than 9.0% for enrollees with diabetes; low-density lipoprotein cholesterol level of less than 130 mg/dL for enrollees with diabetes or after a coronary event; and blood pressure of less than 140/90 mm Hg for enrollees with hypertension. RESULTS: Clinical performance on HEDIS outcome measures was 6.8% to 14.4% lower for black enrollees than for white enrollees (P<.001 for all). For each measure, more than 70% of this disparity was due to different outcomes for black and white individuals enrolled in the same health plan rather than selection of black enrollees into lower-performing plans. Health plans varied substantially in both overall quality and racial disparity on each of the 4 outcome measures. Adjusted correlations between overall quality and racial disparity were small and not statistically significant, ranging from 0.01 (blood pressure control) to -0.21 (cholesterol control in diabetes). Only 1 health plan achieved both high quality and low disparity on more than 1 measure. CONCLUSIONS: In Medicare health plans, disparities vary widely and are only weakly correlated with the overall quality of care. Therefore, plan-specific performance reports of racial disparities on outcome measures would provide useful information not currently conveyed by standard HEDIS reports.

Black or African American↗
PubMed1999

Changes in continuity of enrollment among high-risk children following implementation of TennCare.

BACKGROUND: TennCare, Tennessee's Medicaid managed care program, was introduced in 1994 with the goals of controlling spending and of improving access to health care. OBJECTIVE: To assess changes in the continuity of enrollment following the implementation of TennCare for 2 groups: infants in the first year of life (defined as persons aged 0-12 months in this study) and children hospitalized with a chronic health condition (defined as persons aged 0-18 years in this study). DESIGN: Retrospective cohort analysis. SETTING AND POPULATION: Infants born during 1992 or 1995 to women enrolled in Medicaid or TennCare and 0- to 18-year-old children enrolled in Medicaid or TennCare who were discharged from a hospital during 1992 or 1995 with a chronic health condition. MAIN OUTCOME MEASURES: For infants, failure to enroll an infant in the first 30 days of life or subsequent gaps in enrollment for 7 days or longer during the first year of life. For children hospitalized with a chronic health condition, any gap in enrollment lasting 7 days or longer by 1 year after discharge from a hospital. RESULTS: There was a reduction in the proportion of infants without continuous enrollment in the first year of life following TennCare (19.4% after vs 25.1% before TennCare; odds ratio, 0.69; 95% confidence interval, 0.67-0.72). Improvements in continuity of enrollment for infants occurred despite an increase in the proportion of infants who were not enrolled in TennCare in the first 30 days of life, even though their mother was enrolled at delivery (14.0% after vs 8.0% before TennCare; odds ratio, 1.86; 95% confidence interval, 1.78-1.96). There was a decrease in the proportion of children hospitalized with a chronic health condition who had subsequent gaps in enrollment by 1 year following discharge from a hospital (14.3% after vs 23.3% before TennCare; odds ratio, 0.52; 95% confidence interval, 0.46-0.59). CONCLUSION: For infants in the first year of life and for children hospitalized with a chronic health condition, implementation of TennCare improved continuity of coverage.

Adolescent↗
PubMed2002

Preventive mental health and substance abuse programs and services in managed care.

If effective preventive behavioral health services were available to the millions of Americans enrolled in managed care organizations, the public health impact could be significant. This project sought to summarize published research-based information about effective preventive interventions for mental health and substance use (tobacco, alcohol, and other drugs) shown or likely to have no negative cost impact. Fifty-four studies satisfied seven screening criteria. Their findings demonstrated that preventive behavioral health interventions appropriate for managed care settings have been evaluated and have been shown to be effective. Some produced cost savings or offset costs. Six preventive behavioral health interventions are therefore recommended for managed care.

Adolescent↗
PubMed2002

Rural-urban differences in health risks, resource use and expenditures within three state medicaid programs: implications for medicaid managed care.

This study uses Medicaid claims data for income-eligible enrollees in California, Georgia and Mississippi to compare expenditures, resource usage and health risks between residents of rural and urban areas of the states. Resource use is measured using the Resource Based Relative Value Scale (RBRVS) system for professional services, hospital days and outpatient facility visits; it also is valued at private insurance reimbursement rates for the states. Health risks are measured using the diagnosis-based Adjusted Clinical Group system. Resource use is compared on a risk-adjusted basis with the use of urban Medicaid enrollees as the benchmark. We find that actual expenditures for rural care users are lower than for urban care users. However, because the proportion of Medicaid enrollees who use care is higher in rural than in urban areas in all three states, expenditures per rural enrollee are not consistently lower. Case mix is more resource intensive for rural compared to urban residents in all three states. Although resource usage is not systematically lower overall for rural enrollees, on a risk-adjusted basis they tend to use less hospital resources than urban enrollees. Capitation rates based on historical per enrollee expenditures would not appear to under-reimburse managed care organizations for the care of rural as opposed to urban residents in the study states.

California↗
PubMed1997

Reducing technology costs and risks in a managed care environment.

In the managed care environment, technology life-cycle management is necessary to minimize costs and maximize the quality of patient care. A careful approach to equipment acquisition and management can help managed care providers reduce the cost of delivering services while ensuring the right technology is available when and where it is needed to best serve patients. Proper management of technology assets from planning and budgeting through acquisition, usage and disposal can help managed care facilities reduce cost and risk, increase control, and improve productivity.

Capital Expenditures↗
PubMed2000

Health information networks: enabling care management in IDSs.

To be successful, IDSs require streamlined, information integration across the continuum of care. Having this capability enables IDSs to manage care and costs efficiently, provide physicians with enterprisewide access to eligibility information, and respond to the communication and quality demands of patients. For most IDSs, the quickest and most cost-effective way to achieve overall information-system integration is to implement a health information network (HIN) based on Internet technologies. A HIN enables IDS providers and staff to access requisite administrative and clinical information from throughout the enterprise using a Web browser.

Computer Security↗
PubMed1995

Case management programs: investment in the future.

A well-planned, proactive case management program that focuses on the identification and management of high-risk/high/cost patients can prove to be a valuable investment. FHP, Inc., implemented a pilot Patient Care Management program in the Long Beach/Orange County, California region. The program produced an estimated cost savings of nearly 4 million dollars in its first full year of operation. Results also included improved patient satisfaction, increased quality of care and decreased medical-legal risks. The program is currently expanding to all states where FHP has staff model operations. This article examines the steps utilized in the development of the program, and identifies keys to success.

Adult↗
PubMed1994

Relationship between practice characteristics of primary care internists and unnecessary hospital days.

BACKGROUND: Inpatient utilization review remains a useful approach for hospitals to achieve cost savings, however utilization review efforts need to become more focused and sophisticated. METHODS: In order to identify physicians with a higher percentage of unnecessary hospital days, and to analyze how their practice characteristics distinguished them from their colleagues, 364 consecutive admissions of 57 primary care internists were reviewed concurrently, on a daily basis. Days without acute hospital level of care that occurred while patients were awaiting placement in a rehabilitation or in a chronic care facility were adjusted out of the calculation. Analysis was undertaken to assess the impact of physician age, location of training, Board Certification, practice location, participation in medical training programs, years of experience, and participation in various types of managed-care programs on the level of unnecessary hospital days. Characteristics of the patients and their illnesses were included in the analysis. RESULTS: A large number of unnecessary hospital days occurred although there was no useful segregation of good from poor physician utilizers. Board certification and suburban practice location were associated with a significantly lower percentage of adjusted unnecessary days. Physician members of a closed-panel health maintenance organization had a lower percentage of adjusted unnecessary hospital days (14% vs. 41%, P < .001) when compared with the other primary care internists. Explanations for the difference are discussed. CONCLUSIONS: 1) The patients of primary care internists are still responsible for a large number of unnecessary hospital days; 2) Utilization review efforts need to become more sophisticated and focused; and 3) A change in physician incentives coupled with appropriate staff and systems possibly would be the simplest, large-scale remedy.

Health Services Misuse↗