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Results for “Managed Care Programs”

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At least 469 records · Page 26Linked to original sources
PubMed1997

Claim audits: a relic of the indemnity age?

Traditional claim audits offering quick fixes to specific problems or to recover overpayments will not provide benefit managers with the data and action plan they need to make informed decisions about cost-effective benefit administration. Today's benefits environment calls for a comprehensive review of claim administration, incorporating traditional audit techniques into a quality improvement audit process.

Administrative Personnel↗
PubMed2000

Managed care report cards: evaluating those who evaluate physicians.

Managed care organizations are evaluating doctors, but how well are these organizations being evaluated themselves? This proposal for a report card identifies the necessary features of competent and sophisticated managed care enterprises. It is designed so that purchasers, providers, and patients may appreciate the more substantive issues associated with success in health care management.

Benchmarking↗
PubMed1996

Medicare HMOs: part of the solution or part of the problem in the struggle for cost containment?

The correct answer for salvage of the Medicare program while maintaining acceptable medical care is clearly not available today. Managed care programs for seniors have been an option in the last decade and plans are expanding rapidly into previously untapped areas. Some programs can indeed provide a multiplicity of services and thereby truly integrate and improve existing care plans. Others have less clear cut advantages. For any senior contemplating the options available for medical care under Medicare, HMOs and Medigap type instruments, the most salient advice is "buyer beware." A complete understanding of the options gained and lost by changing medical insurance coverage is essential.

Cost Control↗
PubMed1996

Outcomes and accountability. Can dentistry prove the benefits of care?

As managed care increases in influence, dentists must be prepared to document the efficacy of all treatment modalities in order to maintain control over the care their patients receive. We, rather than third parties, are ultimately accountable for the results of the care we provide. The outcomes assessment process can yield essential, clear evidence of the efficacy, cost-effectiveness and benefits of the care we provide to patients.

Clinical Competence↗
PubMed2002

Challenge and opportunity: nurse practitioner programs partnering with managed care.

PURPOSE: To examine the experiences of nurse practitioner (NP) students who participated in a collaborative educational program between the University of Massachusetts, Amherst, and Health New England (HNE) Health Plan, Springfield, MA. Nurse practitioner faculty and managed care executives shared resources to educate NP students and to address their perceptions about managed care. DATA SOURCES: Verbatim transcriptions and journal writings of students specifically designated as "Partnerships for Quality Education (PQE) trainees" and reports of their fellow classmates, all of whom received varying extent of access to managed care theory, administrative, and clinical experiences within the HNE plan. CONCLUSIONS: The experiences of the PQE trainees revealed a greatly expanded understanding of managed care that challenged students' previous beliefs. They reported greater satisfaction with program participation than their classmates, had an unprecedented opportunity to articulate the NP role to a managed care organization (MCO), and learned that a collaborative, rather than an adversarial, relationship with an MCO produces better outcomes for patients and providers. Many students in the class, including some of the PQE trainees, were concerned, however, about what they perceived as managed care "taking time away from clinical issues," which they considered more important. IMPLICATIONS FOR TEACHING AND PRACTICE: There is a need for balance between both managed care and clinical content in NP programs, yet students must have an intimate grasp of both if they are to survive in today's health care environment.

Education, Nursing, Graduate↗
PubMed2002

On values and democratic policy making: the deceptively fragile consensus around market-oriented medical care.

Market-oriented strategies, embodied in managed competition, have become the primary focus of contemporary U.S. health policy. This dominance reflects the emergence of a bipartisan coalition of support among political elites. This study traces the historical evolution of elite support for the market and suggests that the consensus favoring managed competition is deceptively fragile, with support riven by cleavages in the values used to judge fairness in the allocation of medical care. A unique data set of matched questions asked of both policy elites and the general public is used to document these differences in ethical norms. The implications of these cleavages help to explain three puzzling aspects of contemporary U.S. health policy: (1) the persisting inability to translate the principles of managed competition into politically feasible reforms, (2) the repeated failures to implement demonstration projects intended to test competitive pricing within the Medicare program, and (3) the inability of state regulations to assuage the public's concerns about managed care. Some prescriptions for a more revealing and effective treatment of market reforms in health policy conclude this study.

Consensus↗
PubMed1994

Information management in the age of managed competition.

BACKGROUND: Today's information requirements differ from those of the past, in terms of both the internal and external reporting needs of health care organizations. Demands for information are currently generated by physicians, quality managers, total quality management (TQM) teams, marketing staff, financial managers, regulators, insurance plans, accreditation agencies, purchasers, coalitions, and other customers. DISCUSSION: Health care organizations respond to these demands in different ways, depending on their size and type. Six aspects of information needs that would be relevant under managed competition are analyzed: standardization, linkages among data banks, risk adjustment, comprehensive institution-based indicators and information systems, comprehensive population-based indicators and information systems, and methods for protecting confidentiality of patient records. RECOMMENDATIONS: Six recommendations to hospitals/managed care plans that decide to establish information management systems are made: set goals, set priorities, describe current system, identify external data sources, develop (a plan), and check back (reassess).

Centers for Medicare and Medicaid Services, U.S.↗
PubMed2001

Identifying indicators of laboratory management performance: a multiple constituency approach.

The challenges for laboratory management posed by cost control, managed care, organizational restructuring, information networking and health system integration call for new measures to evaluate how effectively laboratories manage emerging performance expectations. This study identifies the Delphi panel method in achieving consensus on measures of effectiveness and considers a specific application, the identification of indicators of laboratory performance, from the perspective of key constituencies.

Attitude of Health Personnel↗