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At least 505 records · Page 28Linked to original sources
PubMedDate not supplied

Improving rates of advance directive discussions among managed care nursing home enrollees.

BACKGROUND: Discussions about advance directives should be offered to all nursing home residents. Managed Medicare programs for nursing home residents allow for the development of performance improvement initiatives to ensure that these discussions occur and are documented. PURPOSE: To assess the effectiveness of an intervention to increase discussion and documentation of advance directives for enrollees in a managed Medicare program for nursing home residents, and to evaluate whether this intervention affected preferences for cardiopulmonary resuscitation (CPR) and hospitalization among enrollees. SUBJECTS: Participants were 4,248 enrollees in a managed Medicare program in 1996, and 6,598 enrollees in 1997, in Georgia, Maryland, Massachusetts, Minnesota, Arizona, and Florida. DESIGN: Descriptive study of a quality improvement initiative. METHODS: A chart review was conducted in the fall of 1996 to determine the prevalence of documented advance directive discussions among all enrollees, and the preferences regarding CPR and hospitalization. Because the discussion rates varied across sites, and were lower than expected, each site developed strategies to improve advance directive discussion and documentation. One year later, a similar survey was conducted to determine the efficacy of the interventions, as well as to assess the impact, if any, on rates of desire for CPR and hospitalization. RESULTS: Documented discussions of advance directives increased across the six sites from 73% to 85% (P < 0.001). The overall percentage of patients desiring CPR did not change following the intervention (18%). However, there were geographical differences in the desire for CPR among enrollees, with those in Minnesota (8%), Arizona (11%), and Florida (12%) desiring it the least, and those in Massachusetts (20%), Georgia (29%), and Maryland (29%) desiring it the most. The overall percentage of desire for hospitalization decreased from 65% to 62% (P < 0.001). Enrollees in Georgia were most likely to want hospitalization (87%), and enrollees in Minnesota were the least likely to want hospitalization (57%). CONCLUSIONS: In a managed care program, documentation of advance directive discussions can be increased with focused efforts. Overall, most enrollees did not desire CPR, but a majority desired hospitalization. Despite the similarity of interventions and program philosophy across sites, significant geographic variations in desire for CPR and hospitalization remained.

Journal Article↗
PubMedDate not supplied

Use and abuse of the medical loss ratio to measure health plan performance.

This paper examines the use and abuse of the medical loss ratio in the contemporary health care system and health policy debate. It begins with a survey of the ways in which the medical loss ratio has been interpreted to be something it is not, such as a measure of quality or efficiency. It then analyzes key organizational features of the emerging health care system that complicate measures of financial performance, including integration between payers and providers, diversification of payers across multiple products and distribution channels, and geographic expansion across metropolitan and state lines. These issues are illustrated using medical loss ratios from a range of nonprofit and for-profit health plans. The paper then sketches a strategy for improving the public's understanding of health plan performance as an alternative to continued reliance on the flawed medical loss ratio. This strategy incorporates data on structure and process, service quality, and financial performance.

Accounting↗
PubMed1995

Rehabilitation services in an integrated delivery system.

For rehabilitation providers, managed care means cutting costs 20 percent to 40 percent and responding to a major shift from acute inpatient rehabilitation to subacute, outpatient, and home-based services. By becoming more efficient and joining integrated networks, rehabilitation providers can participate in the continuum of care and align their economic incentives with other providers and HMOs. But in this month's Director's Notebook, rehabilitation leaders also worry that the shorter lengths of stay they must impose could compromise patient recovery.

California↗
PubMed1998

Measuring the quality of chiropractic alternative care in a managed care environment.

Today's health care environment is more consumer driven with regard to quality issues, and consumers want open access to alternative care, which includes chiropractic care. Given the growing demand for quality, the majority of the top health care plans are requiring their providers to participate in a credentialing process and an on-site office review. These standards allow managed care organizations to make an informed, objective decision regarding the network selection process of chiropractic providers.

Chiropractic↗
PubMed1998

Promote customer perceptions of value: the ladder of effects.

Seven categories of measures are typically used by managed care organizations (MCOs) in monitoring and evaluating the effects of demand improvement efforts on their own performance: (1) member participation in specific initiatives, (2) changes in member mind-states, (3) member behavior, (4) member health status, (5) member service use, and (6) health care expenditures, as well as (7) a variety of value-adding side effects. These same seven can be even more useful to MCOs in monitoring and demonstrating the value they are delivering to their customers. The potential for the MCOs to extend the use of these parameters and gain added value for themselves thereby are discussed, and specific examples are offered to illustrate this potential.

Consumer Behavior↗
PubMed1996

Selling high quality and low cost: market conditions and successful quality improvement projects.

Many potentially useful health care improvement projects fail to achieve much improvement. Even a technically excellent project can fail because, under certain conditions, economic factors in the health care market do not support high quality and low cost. Most health care markets evolve from the traditional fee for service market through a consolidation phase into risk shared market. At each phase, payment mechanisms will support specific quality and productivity improvement projects and discourage others. For example, the implementation of critical paths/clinical protocols is not supported until the majority of payers pay a fixed cost per illness or covered life. Prior to that point, loss of income for the hospital and/or physicians will inhibit successful implementation. Maximum quality and productivity improvements outcomes can be achieved with minimum efforts when project leaders understand the maturity of their organization's market, and strategic needs. This paper will review the types of payment systems (fee for service, discounted fee for service, and risk shared payments) and identify the types of projects that maximize benefit to the stakeholders involved.

Cost-Benefit Analysis↗
PubMed1999

Quality and accountability: Children's emergency services in a managed care environment.

The fast pace of change in the health care system has sparked growing interest among purchasers, consumers, providers, health plans, and others in evaluating and improving the quality of health services. The Emergency Medical Services for Children Program's Managed Care Task Force recommended the development of a white paper to focus on issues related to quality and accountability in children's emergency medical services in a managed care environment. A literature review was conducted, and a panel reviewed and discussed relevant materials. The panelists then developed recommendations as a resource for managed care organizations, providers of care, professional associations, and federal, state, and local policymakers.

Adolescent↗
PubMed1993

Adolescents and access to health care.

The developmental characteristics and health behaviors of adolescents make the availability of certain services--including reproductive health services, diagnosis and treatment of sexually transmitted disease, mental health and substance abuse counseling and treatment--critically important. Furthermore, to serve adolescents appropriately, services must be available in a wide range of health care settings, including community-based adolescent health, family planning and public health clinics, school-based and school-linked health clinics, physicians' offices, HMOs, and hospitals. National, authoritative content standards (for example, the American Medical Association's Guidelines for Adolescent Preventive Services (GAPS), a multispecialty, interdisciplinary guideline for a package of clinical preventive services for adolescents may increase the possibility that insurers will cover adolescent preventive services, and that these services will become part of health professionals' curricula and thus part of routine practice. However, additional and specific guidelines mandating specific services that must be available to adolescents in clinical settings (whether in schools or in communities) are also needed. Although local government, parents, providers, and schools must assume responsibility for ensuring that health services are available and accessible to adolescents, federal and state financing mandates are also needed to assist communities and providers in achieving these goals. The limitations in what even comprehensive programs currently are able to provide, and the dismally low rates of preventive service delivery to adolescents, suggests that adolescents require multiple points of access to comprehensive, coordinated services, and that preventive health interventions must be actively and increasingly integrated across health care, school, and community settings. Unless access issues are dealt with in a rational, coordinated fashion, America's adolescents will not have access to appropriate health services. Current efforts to minimize current health care expenditures through managed care programs inevitably conflict with efforts to deliver comprehensive preventive services to all adolescents. Use of multiple sites may not represent inadequate access to care. However, as managed care reimbursement continues to expand, school-based clinics and free-standing adolescent health programs increasingly report decreases in reimbursement without a change in demand for services. The Office of Technology Assessment study called for explicit funding and expansion of services for America's youth; since then, a federal Office of Adolescent Health has been authorized, and, by the time this reaches print, should have received appropriations and been staffed. Dryfoos has called for expansion to nearly 5000 comprehensive programs in the coming years. 76 Additionally, The Robert Wood Johnson Foundation has just announced a $23.2 million state-community partnership grant program to increase availability of school-based health services for children and youth with unmet health needs.77 As health care reform efforts move forward,both careful definition of the services adolescents need and adequate financing for these services are essential to ensure access to care for all adolescents.

Adolescent↗
PubMed2003

Public health surveillance of diabetes in the United States.

The Centers for Disease Control and Prevention Division of Diabetes Translation supports a national and state surveillance system that analyzes, interprets, and reports on diabetes risk behaviors, risk factors, care practices, morbidity, and mortality. Data sources include surveys, the U.S. Renal Data System, the Indian Health Service, information on hospital inpatients, birth and death certificates, and special studies to use and to better understand the usefulness of data from managed care, Medicare, and Medicaid for monitoring diabetes. These data are used to define the magnitude and burden of diabetes; monitor changes in burden over time; guide public health planning and policy making, and assess progress toward diabetes objectives, such as those in Healthy People 2010. Challenges facing the diabetes surveillance system are limitations in data sources; the capture of undiagnosed diabetes; tracking key risk factors, such as levels of glycemia and lipids; and surveillance of high- or emerging-risk populations such as racial and ethnic groups, children and youth, and those with prediabetes. Limited resources, competing priorities, and issues of data privacy also challenge surveillance. To overcome these factors, the Division of Diabetes Translation strongly emphasizes partnering with other organizations, such as the Medicare and Medicaid programs, managed care, and other chronic disease programs.

Centers for Disease Control and Prevention, U.S.↗
PubMed1999

Access for low-income children: is health insurance enough?

OBJECTIVE: The Balanced Budget Act of 1997 authorizes $20 billion for states to expand health insurance coverage among uninsured low-income children. This study identifies lessons learned from the Medicaid Extension Demonstration, which was authorized by Congress to experiment with innovative approaches to providing health care coverage for low-income children. The three programs compare and contrast a variety of features that may enhance or detract from access, including a traditional Medicaid expansion, a private indemnity model, and a comprehensive managed care delivery system. METHODOLOGY: Two waves of telephone surveys were conducted with a sample of parents of children participating in the Medicaid Extension Demonstration, and a comparison group of parents of children who were eligible but not participating. Descriptive and multivariate analyses were conducted to determine the impact of the demonstration on access to care. RESULTS: Compared with those who were uninsured, children in the managed care program were more likely to have a medical home and a physician visit and were less likely to have an emergency room visit, and had lower levels of unmet need. Outcomes across the other two demonstration programs were less favorable. CONCLUSIONS: This study suggests that simply providing a Medicaid card or private indemnity insurance card is not enough to ensure access to care. Future initiatives also need to consider the structure of the delivery system, especially the availability of a medical home (with adequate after-hours care), as well as the impact of discontinuous insurance coverage on access to and continuity of care.

Adolescent↗
PubMed2004

Quality of heart failure care in managed Medicare and Medicaid patients in North Carolina.

Use of angiotensin-converting enzyme (ACE) inhibitors and beta-adrenergic receptor blockers in patients with heart failure (HF) remains low despite the results of clinical trials and evidence-based guidelines that support their use. The quality of HF care in managed Medicare and Medicaid programs in North Carolina participating in a HF quality improvement program was assessed. Managed care plans identified adult patients with 1 inpatient or 3 outpatient claims for HF during 2000. A stratified random sample of 971 Medicare and 642 Medicaid patients' outpatient medical records from 5 plans were reviewed by trained nurse abstractors to obtain data regarding type of HF, demographics, comorbidities, and therapies. Left ventricular function assessment was performed in 88% of patients. Among 494 patients with systolic dysfunction, 86% were appropriately treated with respect to ACE inhibitors (73% prescribed, 13% had a documented contraindication). In contrast, beta-blocker therapy was appropriate in 61% (49% prescribed, 12% contraindication). There were no significant differences in drug use by insurance, gender, race, or age. Ventricular function assessment and ACE inhibitor prescription rates are higher than beta-blocker prescription rates among Medicare and Medicaid managed care patients in North Carolina. Opportunities for improvement remain, particularly for beta-blocker use.

Adrenergic beta-Antagonists↗
PubMed2006

Using the PRECEDE model to plan men's health programs in a managed care setting.

Managed care organizations represent an important venue for delivering health promotion programs. However, most health plans do not employ public health strategies that match peoples' needs and preferences to effective behavior change techniques. This article focuses on the planning efforts by Blue Cross and Blue Shield of North Carolina (BCBSNC) to address the problem of underutilization of preventive health care services among adult male members--an issue that has received comparatively little attention in the health behavior arena. BCBSNC planners used the PRECEDE planning process to define issues relevant to the target population and determine appropriate intervention strategies. Increasing perceived susceptibility and severity to disease, perceived benefits of screening, physician recommendation for screening, and health knowledge/awareness emerged as intervention priorities. The PRECEDE planning process yielded important evidence-based information and strategies to address men's underuse of preventive services and led BCBSNC to adopt new systems for planning interventions to promote the health of its members.

Adult↗