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PubMedDate not supplied

Home care for medically fragile children: urban versus rural settings.

The development of managed care programs has allowed children who are medically fragile and technology-dependent to be discharged back to their home communities. Rural and urban settings each have unique characteristics that can affect home care. A number of home-care problems are common to both urban and rural settings, including nursing coverage, respite care, school services, coordination of medical resources, and emergency response protocols. Although the problems may be similar, the solutions often differ and should be adapted to the unique urban or rural settings in which they occur. Approaches to these problems are offered on the basis of experience in providing care management to these children in the Specialized Home Care Program in Michigan. Also explored are the problems of the lack of resources available to children who are medically fragile but not technology-dependent.

Child↗
PubMed2003

Caring for patients under Medicaid mandatory managed care: perspectives of primary care physicians.

The purpose of the study was to describe the experiences of primary care physicians caring for Medicaid recipients in a demonstration mandatory health maintenance organization (HMO) managed care program. The authors collected data through semistructured individual or focus group interviews with 14 physicians and through interviews with the chief executive officers of the three HMOs participating in the demonstration program. Interview questions, developed initially from a review of the literature, addressed physicians' experiences as primary care providers for Medicaid recipients under traditional fee-for-service and under managed care arrangements through the demonstration program. Four themes emerged: providers' hassles and burdens, the complex needs of Medicaid patients, improved access to care under managed care, and individual providers' disconnect from the processes of health policy implementation and program evaluation.

Attitude of Health Personnel↗
PubMed2006

Perceived impact of TennCare reform on patients' health in a medical teaching practice.

From 1994-2005, TennCare, Tennessee's innovative Medicaid managed care program, dramatically expanded coverage to around 1.3 million Tennesseans (roughly 23 percent of the state population) by employing cost savings achieved through capitation and managed care. Rising healthcare costs and a static state budget resulted in program downsizing that started in mid-2005. This cross-sectional survey sought to document the perspectives of TennCare enrollees before disenrollment about the likely impacts of changes in TennCare coverage and benefits. In February 2005, a convenience sample of 89 patients served by an internal medicine resident staffed teaching practice in Memphis, TN, participated in a survey to assess their perspectives about the potential impact of the upcoming disenrollment and benefits limitations. Ninety percent or more expressed concerns that loss of TennCare would lead to health problems, difficulty with paying for prescriptions and difficulty finding alternative health insurance. This survey suggests that before disenrollment, most people served by TennCare believed that loss of TennCare would have serious negative consequences on their health. Further studies are needed to assess the true impact of the disenrollment and benefit cuts and the effectiveness of alternative safety net services for vulnerable Tennessee citizens.

Adult↗
PubMed2006

Outcomes for rural Medicaid clients with severe mental illness in fee for service versus managed care.

This study compared outcomes for rural Medicaid clients with severe mental illness in fee for service versus managed care programs. Interviews were conducted with 305 Medicaid clients in rural Oregon (166 in fee for service and 139 in managed care). Logistic and multivariate regression analyses were used to examine client satisfaction, safety, symptoms, functioning, and family satisfaction in the fee for service versus managed care groups. There was no evidence that conversion of the Medicaid mental health system from fee for service to managed care led to changes in outcomes for rural clients with severe mental illness.

Acute Disease↗
PubMed1998

Using health outcomes data to compare plans, networks and providers.

PURPOSE: To analyze the challenge of using health outcomes data to compare plans, networks and providers. ANALYSIS: Different questions require different designs for collecting and interpreting health outcomes data. When evaluating effectiveness of treatments, tests or other technologies, the question is what processes improve health outcomes? For this purpose, the strongest evidence comes from a double-blind randomized controlled trial. In program evaluations, the question is 'what is the impact of this policy and related programs on health outcomes?' For this purpose, we may be able to randomize subjects, but are more likely to have a quasi-experimental or an epidemiological design. When we compare plans, networks and providers for quality improvement purposes the question is 'do these specific plans perform differently from one another?', or, 'are these specific plans improving their performance over time?' We want to isolate for study the effects attributable to specific plans. Designs that yield strong evidence cannot be applied because we lack experimental control. CONCLUSIONS: When we already have strong evidence linking specific processes of care with specific outcomes, comparing process data may reveal more about performance of plans, networks and providers than comparing outcomes data. Comparisons of process data are easier to interpret and more sensitive to small differences than comparisons of outcomes data. Outcomes data are most useful for tracking care given by high volume providers over long periods of time, targeting areas for quality improvement and for detecting problems in implementation of processes of care.

Benchmarking↗
PubMed1996

Strategic planning for applied pharmacoeconomics programs.

Escalating costs are changing the infrastructure in which health care is provided. Managed care programs are financing an ever-increasing share; rationing has already become reality in at least one state; and the federal government is once again examining the concept of a national health care plan. The primary goal of each of these initiatives is to control cost: the increasing cost of providing drug therapy is a major target. Increasing demands for shrinking resources will demand demonstration of value for money spent. Pharmacoeconomics provides a mechanism to establish the value of drug therapy. Using the strategic planning process, the Division of Pharmacy at M.D. Anderson Cancer Center and the Department of Pharmacy Services at Oregon Health Sciences University Hospital and Clinics have developed pharmacoeconomics programs to provide the focus for ensuring that every dollar spent on drug therapy and pharmaceutical services buys the best outcomes. These two case studies illustrate the processes for developing an applied pharmacoeconomics program and the activities such a program should embrace.

Cancer Care Facilities↗
PubMed1991

Measurement and management of quality in managed care organizations: alive and improving.

Leatherman et al, Schlackman, and McGuirk-Porell et al all provide important examples of how managed care organizations (MCOs) will measure quality in this decade (except for health care status, which none have yet incorporated). All three organizations rely on insurance claims as a data source and quality management as a tool for improving quality; United Health Care and US Health-care use claims data to improve care for the entire membership, a still unrealized potential for MCOs. All three programs, relatively new, can be only minimally evaluated in terms of measurement validity, cost-efficiency, and improvement in the quality of care. The impact of such MCOs depends on policy initiatives, improvements in outcome and process measures, and MCOs' commitment to serve the total population, including the uninsured and Medicaid populations.

Health Services Research↗
PubMed2004

The association between quality improvement activities performed by managed care organizations and quality of care.

PURPOSE: Little data are available to assess the efforts of managed care organizations to improve quality of care. This analysis assessed differences in performance rates between organizations with and without quality improvement activities. METHODS: We reviewed 399 self-reported quality improvement activities submitted by organizations seeking accreditation by the National Committee for Quality Assurance. Processes or outcomes assessed in quality improvement activities were linked to corresponding measures in the effectiveness-of-care database of the Health Plan Employer Data and Information Set (HEDIS). Performance rates for managed care organizations with and without quality improvement activities were then compared. RESULTS: The cross-sectional analysis included 79 quality improvement activities from 50 organizations, covering 12 effectiveness-of-care categories. Each activity had a matching performance score in the database. Financial incentives for providers were associated with substantially higher performance rates in organizations employing this type of intervention. Eight effectiveness-of-care categories had at least four organizations reporting specific quality improvement activities for the care category of interest; statistically significant improvements were observed for follow-up visits for patients after hospitalization for mental illness, checkups after delivery, and screening for cervical cancer. CONCLUSION: Based on objective and audited information, the estimated effects of self-reported quality improvement activities were often small and inconsistent. In some instances, the observed effect was contrary to the expected direction. Limitations of the available dataset and the caveats of a cross-sectional study design precluded a number of analytical options. Longer-term, prospective studies are needed to explore further the relation between quality improvement activities and objective measures of clinical performance.

Accreditation↗
PubMed1987

Competitive health plans and alternative payment arrangements for physicians in the United States: public sector examples.

The Medicaid program in the United States is moving to a competitive managed care system whereby patients no longer have freedom of choice of physicians and physicians are given incentives to provide care cost effectively. The wide variety of competitive managed care programs represents attempts to introduce rationality into the relationship between consumers and providers in a community. Early evidence, based largely on preliminary data analysis indicates that competing plans which place physicians at some financial risk and also employ administrative mechanisms, are more likely to show cost savings than health plans that do not employ these methods.

Cost Control↗
PubMed1998

The outcomes utility index: will outcomes data tell us what we want to know?

PURPOSE: To propose an approach to the evaluation of the utility of an outcome measure for use in making comparisons among health plans, hospitals, networks, or other accountable entities. METHOD: Seven components are recommended for evaluation: whether the outcome is a health outcome; the extent to which expectations for performance can be defined; the role medical care plays in achieving the outcome; the relative complexity of events that produce the outcome; the degree to which attribution can reasonably be made; the suitability of risk adjustment for limiting external sources of variation; and the likelihood that the measure provides perverse behavioral incentives. RESULTS: Illustrative examples are given in each area for scoring the performance of measures on the component. CONCLUSION: Outcomes measurement is of great interest to a variety of potential users. The approach proposed here is intended to provoke discussion and more rigorous development of tools that will help to identify the measures that are likely to produce the most useful information for making comparisons among accountable entities in the health system.

Benchmarking↗
PubMed1998

Accountability for health outcomes and the proper unit of analysis: what do the experts think?

BACKGROUND: An invitational conference was held in Dearborn, MI, in April of 1998 to discuss technical and conceptual issues related to the general topic of using outcomes data to compare plans, networks, and providers. Approximately 150 researchers, clinicians, purchasers, and representatives of accreditation bodies and government agencies attended. SURVEY OF PARTICIPANTS: At the opening session, attendees participated in an electronic survey exercise designed to identify areas of agreement or disagreement on controversial issues related to the main conference topic. MAIN FINDINGS: There was general agreement about the basic concept of health plan and provider accountability for health outcomes, and about the need for further development of data sources and case-mix adjustment models. There was disagreement about other issues, including questions of who should bear the cost of collecting outcomes data and whether results should be analyzed at health plan, network, or individual clinician level. CONCLUSION: A group of experts agreed on the importance of reporting comparative outcomes data, but disagreed on many of the technical details of how that could best be done.

Attitude of Health Personnel↗
PubMed1996

Managed competition and California's health care economy.

There is evidence in California of a broad decline in health care costs to employment groups adopting managed care and managed competition--premium reductions up to 10 percent. National comparisons and utilization data generally confirm the beginning of lower costs. Large California medical groups and health systems have responded to pressure by finding ways to reduce costs and improve quality. While examples are encouraging, there is room for improvement. Two levels of competition have emerged and continue to evolve: carrier competition and delivery system competition. Each model has strengths and limitations, but the existing mix is driving down costs.

California↗