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PubMed2000

HIV/AIDS managed care program.

Approximately one-half of all patients with HIV infection who are under care have Medicaid as the third party payor. Unlike Medicare, Medicaid is a state-specific program that has huge variations in reimbursement strategies. Multiple studies have shown that care for persons with AIDS is about $20,000/year, but reimbursement through various state Medicaid programs varies about $100/m/m to $2800/m/m despite the fact that expectations for care are identical. Hopkins has a major commitment to persons with HIV infection with a program that now includes 30 faculty members and a support staff of 170. With the introduction of mandatory managed care for Medicaid recipients in July, 1997, we were confronted with the issue of substantial downsizing with abandonment of over half of our patients, or learning the transition to managed care. This has been a steep learning curve involving negotiations with the state Medicaid office, reorganization of our clinic, careful scrutiny of our database regarding resource utilization and cost, education of providers, and longitudinal collection of new information and integration of the rapid changes in the field. In the process of this transition, we learned that there are precious few resources to provide guidance and that there is a perceived need for assistance by HIV providers throughout the country. Consequently, we have now established the "HIV Managed Care Network" with substantial funding from diverse sources to support education, data collection, and public policy review. It is premature to evaluate performance since most of these activities have just begun, but we expect that this Network will serve as a demonstration model for methods to deal with chronic diseases under managed care.

Acquired Immunodeficiency Syndrome↗
PubMed1999

Methadone maintenance and state Medicaid managed care programs.

Coverage for methadone services in state Medicaid plans may facilitate access to the most effective therapy for heroin dependence. State Medicaid plans were reviewed to assess coverage for methadone services, methadone benefits in managed care, and limitations on methadone treatment. Medicaid does not cover methadone maintenance medication in 25 states (59 percent). Only 12 states (24 percent) include methadone services in Medicaid managed care plans. Moreover, two of the 12 states limit coverage for counseling or medication and others permit health plans to set limits. State authorities for Medicaid and substance abuse can collaborate to ensure that appropriate medication and treatment services are available for Medicaid recipients who are dependent on opioids and to construct payment mechanisms that minimize incentives that discourage enrollment among heroin-dependent individuals.

Humans↗
PubMed2004

Use of asthma medication dispensing patterns to predict risk of adverse health outcomes: a study of Medicaid-insured children in managed care programs.

BACKGROUND: Regular use of inhaled anti-inflammatory (AI) medication improves outcomes for children with persistent asthma. OBJECTIVE: To relate 3 measures of asthma medication dispensing to physical health and hospital-based events among children with asthma who were enrolled in 1 of 5 managed care health plans. METHODS: Parents of Medicaid-insured children with asthma were interviewed at baseline and 1-year follow-up. Utilization data were collected from the health plans in which the children were enrolled. Subjects were stratified into 3 subgroups according to asthma severity: intermittent asthma; persistent asthma for which beta-agonist (BA) medication was dispensed infrequently (< or = 3 times per year); and persistent asthma for which BA medication was dispensed frequently (> or = 4 times per year). RESULTS: Baseline interviews were completed by 1,663 parents (63% response rate), 1,504 of whom were enrolled in their health plan for at least 11 months during the baseline year. Follow-up interviews were completed by 1,287 (86%) of the 1,504 parents. Among the subgroup of children with persistent asthma for whom BA was dispensed frequently, those who had 1 to 3 AI dispensings had a greater risk for hospital-based events than those with 6 or more AI dispensings. Baseline-year AI medication utilization patterns were not associated with follow-up-year outcomes. No clinically meaningful association was found in subgroups with less severe asthma; however, few AI medications were dispensed to these children. CONCLUSIONS: Policymakers and clinicians who wish to use medication-based measures to evaluate quality of asthma care should consider counting the number of times AI medication is dispensed among children with more severe asthma.

Administration, Inhalation↗
PubMed1998

Application of a diabetes managed care program. The feasibility of using nurses and a computer system to provide effective care.

OBJECTIVE: Treatment of patients with diabetes often falls short of recommended process and outcome guidelines. To improve the quality of the provided diabetes care, a program (the Comprehensive Diabetes Care Service [CDCS]) using a computerizing tracking and recall system in conjunction with nurses following protocols was implemented in a managed care setting. The impact of this program was studied and compared to the care provided to patients in another managed care setting. RESEARCH DESIGN AND METHODS: Patients followed in the CDCS who completed a diabetes education course were compared with patients followed in a group model health maintenance organization (GMH) who also completed a diabetes education course. CDCS patients received routine care in the program. GMH patients came to the CDCS yearly to have a diabetes evaluation. A chart review was also performed on their GMH outpatient records. RESULTS: Initial HbA1c levels were higher in the CDCS group than in the GMH group (median of 11.9 vs. 10.0%). In the CDCS patients, HbA1c levels not only fell significantly but were also significantly lower (P < 0.05) than in the GMH patients during the 2nd and 3rd year of follow-up care. There were no significant changes in HbA1c levels in the GMH patients. When CDCS patients were divided into compliant and noncompliant patients, the median HbA1c levels in compliant patients was 8.2%, compared with 11.5% in the noncompliant group. The CDCS patients who needed treatment for hypercholesterolemia were more likely to have a lowering of their cholesterol levels than the GMH patients. All process measures, such as yearly measurement of HbA1c levels, lipid levels, and foot and retinal exams, occurred much more frequently in the CDCS patients. CONCLUSIONS: The system developed and implemented for managing diabetes improved both outcome and process measures. The comparison group, followed at another managed care setting, received the care consistent with the average (suboptimal) quality of care provided to patients with diabetes in the U.S. Therefore, by using innovative systems of management, the treatment of patients with diabetes can be greatly improved.

Adult↗
PubMed2003

Enrollee satisfaction with three Florida Medicaid managed care programs.

A study was undertaken to compare adult enrollees' satisfaction with three Medicaid Programs operating in South Florida: (1) the provider service network (PSN), (2) MediPass, and (3) Medicaid HMOs. The Consumer Assessment of Health Plans Study 2.0 Medicaid Adult instrument was used to collect information on four global ratings and five composite ratings. MediPass enrollees were satisfied with their overall health care, whereas PSN enrollees gave only average scores for their doctors, specialists, overall health care, provider communication, and staff helpfulness. The HMO enrollees were satisfied with their specialists, health plan, access to care, promptness of care, staff helpfulness, and member/customer service. Improvements in satisfaction would require different interventions in each of the programs.

Adolescent↗
PubMed1999

Oversight mechanisms in public managed care programs: from little oversight to negotiations to shared decision-making.

An expanded range of oversight mechanisms is being adopted to hold public human service programs more accountable to funding sources as well as consumers, family members, and providers. Most of these approaches are hierarchical in nature. Some involve negotiated agreements and each is designed to meet certain goals and functions. Each utilizes different forms of decision-making. Stakeholders prefer to be part of a shared decision-making process. Understanding these underlying premises can help to assess the strengths and weaknesses of each method and can suggest how to most effectively utilize combinations of approaches to improve program performance. Whether we will move toward a new paradigm emphasizing participation and collaboration rather than more formal structural approaches is yet undetermined but will greatly affect how programs are monitored and evaluated in the future.

Consumer Advocacy↗
PubMed2002

Health care services utilization at the end of life in a managed care program integrating acute and long-term care.

BACKGROUND: The period preceding death is often characterized by increased utilization of medical resources. There is an ongoing debate on the reasons for and the appropriateness of increased utilization at the end of life. OBJECTIVES: To study end-of-life practices in the PACE program and to assess the contribution of individual characteristics versus program site to the variation in use of services. RESEARCH DESIGN: Retrospective analyses of utilization and health status data for the last 3 years before death. Multivariate regression techniques were used to estimate models predicting utilization of services and the percent of variation explained by individual characteristics and program sites in relation to time from death. SUBJECTS: The study comprised 2160 persons enrolled in 10 PACE sites who died before 2000. MEASURES: Monthly utilization by service type (eg, hospital, nursing home, primary care physicians), socioeconomic, and health status data. RESULTS: Utilization of health services increases as early as 7 months before death, with the largest increase in the last month. The increase is dominated by hospital use. During the last month before death variation across program sites explains twice as much of the variation in service utilization as does variation in individual characteristics. CONCLUSIONS: The variation in end-of-life practices across PACE program sites, which are not attributed to differences in individual characteristics, raises two important questions: what are the causes for these variations; and are these variations desirable? Further research is required to answer both questions.

Activities of Daily Living↗
PubMed2003

Contrasting outcomes of older versus middle-aged and younger adult chemical dependency patients in a managed care program.

OBJECTIVE: This study examined how well older chemical dependency patients succeed in treatment relative to middle-aged and younger patients in a mixed-age private HMO outpatient program. To predict successful outcome, we tested a model incorporating age group differences in individual, treatment and extratreatment factors. METHOD: The sample included 89 patients aged 55 and over, 379 patients aged 40 to 54, and 736 patients aged 18-39 (N = 1,204). Baseline measures included DSM-IV substance misuse diagnoses, Addiction Severity Index (ASI), psychiatric symptom checklist, sources of suggestion to enter treatment, treatment history and motivation. Outcome measures were abstinence rates and ASI score 6 months posttreatment. RESULTS: At baseline, older adults showed higher levels of alcohol dependence, lower rates of drug dependence and lower psychiatric symptoms relative to younger individuals. Source of suggestions to enter treatment differed by age. Older and middle-aged patients were more likely to have an abstinence goal and to stay in treatment longer than younger adults. At 6 months posttreatment, 55% of older adults reported abstinence in the preceding 30 days, versus 59% of middle-aged adults and 50% of younger adults (p = .035). CONCLUSIONS: Lower rates of dependence and hostility, and greater abstinence motivation and length of stay in treatment--all of which were associated with greater age--positively affect prognosis of older adults in treatment.

Adolescent↗
PubMed2004

Effect of an innovative medicare managed care program on the quality of care for nursing home residents.

PURPOSE: We sought to assess the quality of care provided by an innovative Medicare+Choice HMO targeted specifically at nursing home residents and employing nurse practitioners to provide additional primary care over and above that provided by physicians. The underlying premise of the Evercare approach is that the additional primary care will reduce the rate of untoward events and reduce the use of hospitals. Four aspects of quality were assessed: mortality, preventable hospitalizations, quality indicators derived from the Minimum Data Set, and change in functioning. DESIGN AND METHODS: The care provided by Evercare was compared with that for two control groups: (a) other residents in the same homes not enrolled in Evercare and (b) residents in homes in the same geographic area that did not participate in Evercare. Data came from various sources, including the Minimum Data Set. Utilization was based on Medicare data for controls and United Healthcare data for Evercare residents. Survival analysis was used to estimate mortality rates. Various risk adjustment methods were applied to the quality indicators. RESULTS: The hazard rates of mortality were significantly lower for Evercare residents than for other residents in the same nursing homes. Evercare residents had fewer preventable hospitalizations; the difference was significant for one control group. The rates of quality indicators and functional change were equivalent. IMPLICATIONS: Evercare, with its use of nurse practitioners, represents a model that can provide more efficient care that is of at least comparable quality.

Activities of Daily Living↗
PubMed2001

Assessing use of primary health care services by very low-income adults in a managed care program.

OBJECTIVE: To assess the effect of providing free health care services to low-income adults. METHODS: We measured access to primary care services by enrollees with 4 chronic medical conditions in the General Relief Health Care Program (GRHCP), a program designed for adults receiving General Relief (GR). Implemented by the Los Angeles County Health Department in October 1995, the GRHCP is composed of private and public health care facilities. As adults registered for GR, they were asked to complete a baseline health survey, were enrolled in the GRHCP, and assigned a health care provider. A total of 8520 surveys were completed between September and November 1996 (98% response rate). The analyses of this article are limited to individuals (N = 2164) who reported a history of hypertension, diabetes mellitus, a nonresolving cough, or substance dependence. We reviewed medical records to determine whether new GR recipients had visited their designated GRHCP provider within 4 months of enrollment and used multivariate logistic regression to assess the effect of individual patient factors on the use of free health care. RESULTS: A total of 17% of individuals visited their assigned GRHCP provider within 4 months of enrollment. In multivariate analysis, patients were more likely to have made a visit if they were younger than 50 years, were female, were Asian/Pacific Islander, reported needing to see a physician, or had seen a physician within 12 months. CONCLUSIONS: It is not sufficient to merely supply the name and address of a health care provider to this population. More aggressive efforts should be attempted to increase utilization of services for patients with medical conditions responsive to ambulatory care.

Female↗
PubMedDate not supplied

Psychiatric service utilization and cost for persons with schizophrenia in a Medicaid managed care program.

A pre-post study design was used to look at changes in behavioral health care services and costs for Medicaid-eligible individuals with schizophrenia in a managed care (MC) carve-out compared to a fee-for-service (FFS) program in Pennsylvania between 1995 and 1998. Statistically significant reductions of 59% were found in hospital expenditures in the MC program compared to 18.3% in the FFS program. The decline in hospital costs was due to dramatic fee reductions in the MC site. No significant differences in overall ambulatory utilization were found in either program; however, ambulatory expenditures rose 57% in the MC program versus a decline of 11% in fee for service. The ambulatory cost increase resulted from a cost shift between county block grant funds, and Medicaid funds, with no additional revenues provided to outpatient providers. Study implications are that cost reductions from MC are mainly due to reducing utilization and payments to hospitals, similar to the findings for private sector programs.

Adult↗