SEARCH · Search PubMed
Search indexed PubMed citations on genomics, clinical trials, systematic reviews and public health. Explore titles, authors and supplied subject terms, then open the PubMed record.
Quote a phrase for an exact phrase match. Source license links do not imply unrestricted reuse.
This article presents a brief overview of managed care and discusses the role of case management. Characteristics of each are given along with a brief history, description of current models, and a forecast of the next generation. Major issues and implications for social work and discharge planning are also covered.
The rising cost of health care has increased the call for cost control. The pressing need to control cost, coupled with the increase in managed care and prospective payment, has placed new urgency on administrators and clinicians to work collaboratively in providing efficient and effective care. We have developed the Integrated Inpatient Management Model (IIMM) to assist in this collaborative effort. We describe the IIMM's clinical information system that provides decision support to both administrators and clinicians. This clinical information system is the information backbone for the development and monitoring of practice guidelines or critical pathways. An integrated information system of this type is essential if hospitals are to prosper during the next decade.
Managed care organizations won't work with a facility unless it offers what they need. These eight tips--and one case study--outline the key procedural changes and adjustments in attitude longterm care providers are making to accommodate managed care.
In the midst of the trepidation surrounding the home care industry during this advent of managed care, one agency has developed a strategic plan to survive and improve under this new health care system. A crucial part of this plan is the careful encouragement and specialized training of middle managers.
Clinical pathways are designed to map the course of medical or surgical interventions and their expected outcomes. They take into account standards of care and the human and material resources needed to provide specific services. Clinical pathways promote cost-effective, high-quality care and thereby help to standardize practice protocols and coordinate care. Healthcare organizations can decrease lengths of stay, reduce costs, and win more managed care contracts by developing and implementing comprehensive clinical pathways. Pathways can also make carve-outs and other specialty contract services easier to manage.
If managed care leaders are able to achieve their goals of enhancing total well-being within a capitated system of care, they must attend to the broad new societal interest in spiritual perspectives and find ways to integrate them into their structure of care. Imaginative and sensitive members of many professions, particularly those who acknowledge the value of spirituality in their own lives and are convinced of its value in healing, will likely spearhead this integrated movement. Promoting individuals' total well-being necessitates an acknowledgement that everyone has a unique personal spirituality that needs to be addressed at times of crisis, such as illness or hospitalization. Further, attention to the spiritual dimensions of problems that result in high healthcare costs, such as violence, alcoholism, and the fear of death, can help reduce those costs. The process of grief also needs to be addressed in healthcare settings, for professionals as well as patients, to enhance understanding, acceptance, and the quality of care. People recover and retain health through a balanced integration of physical, spiritual, and community aspects of their lives. If professional chaplains who have emphasized crisis and acute care in their ministry styles are to contribute to this integrative healing and its adoption into managed care systems, they may need to explore broader frameworks, holistic concepts of healing processes, motivations for self-care, and a personal holistic balance.
THIS PAPER OFFERS ten common sense principles that will help project managers define goals, establish checkpoints, schedules, and resource requirements, motivate and empower team members, facilitate communication, and manage conflict.
While managed care has caused great disruption, it has also provided physician executives with a natural leadership raison d'être. Managed care, with all its pros and cons, is largely a response to certain unrelenting trends. The core functions of leaders comprise the stewardship of organizations and colleagues in response to these trends. Four trends are explored: (1) The demise of open-ended funding of American health care; (2) continued competition for health care resources; (3) thriving pluralism; and (4) patients continually adjusting to assure themselves of appropriate health care access, quality, and service. In the 21st century, the industry will need a new brand of leader, one capable of balancing the needs of the professionals with the business and accountability requirements of a permanently competitive and resource-constrained service industry. The keys to successful leadership in the future include: (1) Clear service differentiation and a compelling vision to match it; (2) recruiting and retaining top clinical talent, including the required return to physician self-direction and governance; (3) successful partnerships with others outside your organization; and (4) a steady focus on performance in all its dimensions.
Health care is a data-sensitive and data-rich industry. Designers of health administration curricula recognize that future health care providers and managers must be trained to use available analytical and database information technology (IT) to transform these data into information helpful to the decision-maker. However, as the data available to administrators and clinicians proliferates, additional skills are needed to select data that is pertinent and useful. This paper presents the results of the collaboration of partners from Bohemia and University of Nevada and focuses on three areas: threats to the effective use of data to support health care decision-making;. health care decision support research and training strategies; future cross-disciplinary collaboration in health care decision support. Advanced IT methods have the potential to assist clinical and managerial decision-making. If further discussion is stimulated about the introduction of advanced IT methods into the health care management curriculum and research agenda, this paper will achieve its goal.
This section of the Annals of Health Law represents a compilation of materials concerning the state regulation of managed care. The following materials were first presented at the annual meeting of the American Association of Law Schools ("AALS"), Section on Law, Medicine and Health Care in January 1999. Chairman John Blum introduces the subject and questions the dual role assumed by state and federal authorities in regulating managed care.
Downsizing of personnel and budgets demands effective means of managing patients' demand for care to ensure that care assets are appropriately utilized. Preliminary data indicate that the Central Triage concept of demand management is effective, efficient, and satisfactory to patients. As a centralized portal to care for individuals presenting without appointments, registered nurses screen and triage via protocol. The nurses send patients to the Emergency Center, make same-day appointments, or provide self-care education as indicated. During the first 9 months of operation, Central Triage inprocessed 35,231 patients. Twenty-three percent were determined to have self-care deficits and received education to assist them in meeting their current self-care demands. Follow-up of 10% of the patients receiving self-care education revealed that 88% improved without further intervention and 95% were satisfied with the care they received. Central Triage has demonstrated an annual cost avoidance exceeding $2,500,000.
OBJECTIVE: To examine the perceptions of health plan pharmacy directors about drug costs and utilization drivers, interventions the plans use to control drug expenditures, and strategies considered necessary to permit continued provision of a comprehensive drug benefit. STUDY DESIGN/METHODS: A multipart survey developed and mailed to 500 pharmacy directors of managed care organizations across the country. RESULTS: The survey respondents (response rate = 18%) represented managed care health plans in the following percentages: 49% of respondents were from network/independent practice associations; mixed-model health maintenance organizations (HMOs), 20%; group HMOs, 15%; and staff-model HMOs and network/preferred provider organizations, 8% each. Drug mix and utilization were reported to be the primary drivers of drug expenditures. Half the respondents rated inflation as a somewhat strong cost driver. Interventions the health plans use to control drug expenditures include formularies, generic substitution, preauthorization, manufacturers' rebates, drug benefit design, physician profiling, target drug programs, academic detailing, and tiered copays. With the exception of formulary use, generic substitution, and manufacturers' rebates, which all the plans have instituted, the types of interventions used by the different model types vary widely. More than half the pharmacy directors reported generic substitution, drug benefit design, and differential copays as very effective interventions used to control drug costs. CONCLUSIONS: The majority of pharmacy directors predict continued double-digit increases in drug expenditures over both the short term and the long term. Of the respondents, 91% reported that additional limits and/or exclusions to the benefit design would be necessary to control these increases. To continue providing a comprehensive drug benefit, 54% indicated that they would have to achieve sufficient cost savings in other areas to offset increases in drug costs.
Disease state management (DSM) offered in a community-based setting is convenient for the consumer, driven by "best practice" protocols, delivered by nursing specialists, supported by the newest information technology, outcome-driven, and the ultimate in clinically integrated delivery systems. Because the DSM is delivered in the lowest cost setting, the home or workplace, it also offers significant cost savings. Community-based DSM will likely be a central component of 21st century health care and holds many opportunities for entrepreneurial nurse managers. This article describes a community-based DSM that has achieved excellent clinical outcomes, high patient satisfaction, high physician satisfaction, and substantial cost reduction.
Reap the benefits of an effective cholesterol management program. Only a small number of patients who could benefit from cholesterol-lowering therapy are actually receiving optimal treatment. However, a systemized approach to the management of such patients can deliver better control and lower costs down the road by preventing cardiac events. Find out the components of a successful cholesterol-lowering DM program, and get advice on how to implement your own program on a large or small scale.
A group of advanced practice nurses partnered with a major insurer in the design and implementation of a care coordination model for high-risk older adults. This article will discuss the process of such an undertaking, highlighting the successes and barriers encountered. The key elements of this program included early identification and regular reassessment of each member's acuity level; fostering close partnerships between individual or teams of APRNs and groups of physicians; and uninterrupted clinical management of high-risk members across the health care continuum. This model was designed to achieve the following outcomes: to support the physician management of high-risk, chronic individuals; to increase or maintain the health of members; and to reduce health care costs. Outcome studies have demonstrated a substantial net savings by decreasing acute care admissions by 54%, reducing hospital days by 42%, and trimming primary care physicians' and specialists' visit costs by 37%. There was a 33% reduction in the overall costs of health care for members enrolled in this program. Physicians and members both rated their satisfaction with the APRN-based model of care as very high.
In a recent speech at the Graduate School of Management, University of California, Irvine, managed care architect Paul M. Ellwood, Jr., MD, outlined an ambitious vision for a dramatic new business model and clinical plan for health care of the future. Here's the complete text of his landmark speech, along with an update on where the plan stands today.
Over the last decade managed care has become the dominant form of health care delivery, because it has reduced the cost of health care; however, it has also created serious conflicts of interest for physicians and has threatened the integrity of the traditional physician-patient relationship. In this Article, Dr. Grochowski argues that the efficiencies created by managed care are one time savings and will not in the long run reduce the rate of rise of health care expenditures without a concomitant plan to ration health care. He explores the traditional physician-patient relationship and concludes: a) that while rationing of health care is inevitable, physicians must not ration care at the bedside; b) that physicians must be advocates for their patients; c) that physicians must avoid conflicts of interest whenever possible; d) that physicians must put the needs of the patient before their own self-interests; and e) that physicians must act in ways to promote trust in their relationship with patients.
Successfully communicating value to management starts by gaining visibility and by knowing what management wants to hear. Communicating budget information, including cost savings and time value of money, is an essential skill for the occupational health nurse. The occupational health nurse must be able to speak the language of business to make a meaningful impact in the 21st century work environment.