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PubMed1999

Depressive symptoms and plan switching under managed care.

OBJECTIVE: A central assumption underlying managed care is that plan switching is a viable option for enrollees when they are dissatisfied. The authors used a national employee survey to test the hypothesis that this mechanism is less effective for enrollees with high levels of depressive symptoms than for the remainder of the population. METHOD: The study used data from the Employee Health Care Value Survey, a 1993 survey of 20,283 employees of three major corporations. The authors used the Medical Outcomes Study 36-Item Short-Form Health Survey to identify individuals with the highest decile of depressive and physical symptoms. They examined the relationship between symptoms and dissatisfaction and, for dissatisfied individuals, how symptoms predicted plan switching. Multivariate models were used to control for potential demographic, health, and health coverage confounders. RESULTS: Depressive and physical symptoms were both associated with dissatisfaction with care. Unlike physical symptoms, depressive symptoms were associated with a significantly lower likelihood of actually disenrolling among people who were dissatisfied or who intended to disenroll. This effect was most pronounced for satisfaction with administrative aspects of care (e.g., gatekeeping, utilization review). CONCLUSIONS: People with high levels of depressive symptoms appeared to be less willing or able to act on their dissatisfaction by switching plans. In particular, they were willing to tolerate higher rates of dissatisfaction with the administrative aspects of their health coverage without disenrolling. Plan switching is an essential mechanism underpinning a health care system predicated on competition; it may be less effective for people with depressive disorders.

Attitude to Health↗
PubMed2001

Risk transfer and accountability in managed care organizations' carve-out contracts.

OBJECTIVE: This study examined characteristics of contracts between managed care organizations (MCOs) and managed behavioral health organizations (MBHOs) in terms of delegation of functions, financial arrangements between the MCO and the MBHO, and the use of performance standards. METHODS: Nationally representative administrative and clinical information about the three largest types of commercial products offered by 434 MCOs in 60 market areas was gathered by telephone survey. These products comprised services provided by health maintenance organizations, preferred provider organizations, and point-of-service plans. Chi square tests were performed between pairings of all three types of products to ascertain differences in the degree to which claims processing, maintenance of provider networks, utilization management, case management, and quality improvement were delegated to MBHOs through specialty contracts among the various types of products. Contractual specifications about capitation arrangements, risk sharing, the use of performance standards, and final utilization review decisions were also compared. RESULTS: For all types of products, almost all the major functions were contracted by the MCO to the MBHO. Although most contracts assigned some risk for the costs of services to the MBHO, the degree of this risk varied by product type. Except in the case of preferred-provider organizations, a large number of performance standards were identified in MCOs' contracts with MBHOs, although financial incentives were rarely tied to such standards. CONCLUSIONS: MCOs that contract with MBHOs place major responsibility, both financial and administrative, on the vendors.

Contract Services↗
PubMed1995

Cost-effective inpatient care of neuropsychiatric patients.

Managed care has decreased the frequency of hospitalization for psychiatric disorders, and it may have an especially strong impact on neuropsychiatric patients. The use of targeted, cost-effective interventions improves the quality of patient care and can assist with approval of funding for inpatient care by utilization review agencies.

Cost-Benefit Analysis↗
PubMed1981

Shifting from external to internal provision of mental health services in a health maintenance organization.

A health maintenance organization whose mental health services had been supplied under contract by two successive external providers changed in 1978 to in-house provision of most services for both HMO and fee-for-service patients. The changeover necessitated a greatly enlarged staff, development of a treatment philosophy and utilization review procedures, and establishment of good cmmunications with external providers who supplied inpatient services. One objective of the change to in-house services was to further reduce hospital admissions and hospitalization costs; comparisons of admissions and costs over a five-year period before and after the change indicated substantial reductions in both areas.

Fees and Charges↗
PubMed1981

A community support system's use of state hospitalization: is it still necessary?

The development of the community support system model and other efforts to decentralize psychiatric care for the severely disabled has made the future role of the state psychiatric hospital uncertain. The authors studied patient admissions from a community support program in New York State to a state psychiatric hospital over a period of 18 months. They found that the program made very little use of the state hospital, accounting for only ten of the county's 33 admissions. The findings also suggest that refractory patients, staff fatigue, and restrictive utilization review criteria applied to the local general hospital were the primary reasons for continued use of the state hospital. The authors conclude that while the state hospital's front-line treatment role may no longer be necessary, the institution may be needed to care for those few patients whose illnesses do not respond well to current treatment alternatives.

Community Mental Health Services↗
PubMed1988

Quality assurance in mental health care.

Quality assurance activities, in place at all institutions accredited by the Joint Commission on Accreditation of Healthcare Organizations and many other agencies, are sure to play an increasing role in the mental health care field. This paper familiarizes mental health professionals with the terminology and activities of quality assurance and how they relate to other health care monitoring programs, such as utilization review, peer review, risk management, and credentialing and privileging. The historical development of quality assurance and special problems encountered in trying to quantify the quality of psychiatric care are also discussed.

Humans↗
PubMed1991

A checklist of hospitalization criteria for use with children.

Each year in the U.S. more than 130,000 children are hospitalized for psychiatric reasons. The decision to hospitalize a child is based on a complex set of factors. In this study, a 12-item checklist of criteria for hospitalization adapted by the authors was tested for its ability to predict hospitalization in a cohort of 389 children between the ages of two and 12 who were evaluated for either inpatient or outpatient treatment. Eighty-seven (22 percent) of the children were subsequently hospitalized. In 95 percent of the cases, the checklist was able to correctly predict whether the patient was hospitalized. A shorter checklist of six items was also able to predict the subsequent form of treatment in 95 percent of the cases. Although such checklists cannot take the place of informed clinical decisions, they can serve as a guide to decision making, especially for inexperienced mental health workers, and as a tool for utilization review when treatment decisions are questioned.

Child↗
PubMed1994

Coverage of mental health and substance abuse services under a single-payer health care system.

Health care reform proposals based on a single-payer system of health care insurance were introduced in the U.S. Congress in 1992 and 1993 but were superseded by the Clinton Administration's health care reform proposal, which was based on managed competition. In a single-payer system, the government collects all health care funding and pays private- and public-sector providers; similar providers are paid the same rate. Other features include consumer choice of providers, distribution of risk of high utilization over the entire nation, and control of health care expenses via an annual national health care budget. Such proposals cover outpatient, inpatient, and long-term care and case management services for mental illness and substance abuse disorders, call for periodic utilization review of continuing mental health care, and eliminate the distinction between public and private services based on limits of coverage. The last provision particularly affects severely or chronically mentally ill persons who are likely to exhaust their private insurance coverage.

Health Care Reform↗
PubMed1996

Length of inpatient stay and recidivism among patients with schizophrenia.

OBJECTIVE: The study examined whether length of hospital stay is related to recidivism among psychiatric patients. A quasi-experimental approach was used to address limitations of controlled and epidemiological research. METHODS: Three matched groups, each consisting of 55 inpatients with schizophrenia, were selected from public psychiatric units with different mean lengths of stay. Regression models were used to compare the groups on three variables: time to first readmission (survival analysis), number of readmissions (ordinal logit regression), and total time in the community in the postdischarge year (multiple linear regression). RESULTS: An analysis based on the units with different lengths of stay, which was similar to that typically used in controlled studies, found no differences in the three outcome measures. However, a second analysis that examined data for all patients irrespective of their unit assignment found that inpatients treated for 30 days or less relapsed sooner than those with stays longer than 30 days. The disparity in results was largely due to overlapping quasi-experimental conditions: many patients on the short-stay units had a long lengths of stay, and vice versa. The first analysis supports an administrative policy of short stays. The second reinforces previous findings that a group of patients, primarily young males with onset of illness at an early age and multiple previous hospitalizations, is at greater risk of relapse with short-term treatment. CONCLUSIONS: The apparent contradiction between a unit- or patient-based analysis suggests that unit-based results should be interpreted with caution when used to make clinical or utilization review decisions.

Adult↗
PubMed1989

The effect of precertification on the rate of hospitalization of patients with low back pain. A case study comparing hospitalization rates of patients covered by workers' compensation and no-fault automobile insurance in New York State.

This report is a study of the rates of hospitalization of two similar groups of patients with a diagnosis of medical low back pain resulting from an injury. It is based on a 7-year experience with utilization review. None of the patients had met the minimal criteria for hospitalization described by the "Reference Criteria for Short-Stay Hospital Review" of the American Medical Association (1). One of these two groups was required to undergo a preservice review (precertification) before hospitalization. The other group did not undergo this precertification. This study tests the hypotheses that there is a significant incidence of unnecessary hospitalization of patients with medical low back pain and that precertification does reduce this rate of hospitalization. It also tests the hypothesis that race, age, and gender correlate with this unnecessary hospitalization. Further, it examines the relationship between the precertification process and the time of admission and the length of stay once admitted. The methods used are defined, and the controversy surrounding precertification and unnecessary hospitalization in general, and for low back pain in particular, is described.

Age Factors↗
PubMedDate not supplied

Choosing cephalosporins for the formulary.

Proper selection of antibiotics for any formulary requires cooperation and communication with members of the pharmacy and therapeutics (P&T) committee and departments of infectious diseases, microbiology, and epidemiology. Ideally, P&T members need to know their institution's incidence and sources of infection (hospital- or community-acquired), antibiotic cure rates, and the adverse effects profiles of antimicrobial agents used. In addition, members need to be briefed on the findings of antibiotic utilization reviews performed. In vitro activity should be compared among similar classes of antibiotics and, when possible, local resistance rates should be considered. The pharmacokinetic properties of an antibiotic, such as peak concentration, protein binding, distribution characteristics, and elimination half-life, should be evaluated during the selection process, as should total cost of the drug, including costs associated with monitoring therapy. The three generations of cephalosporins are used as examples here to delineate differences in potency, pharmacokinetics, efficacy, and potential for causing adverse reactions during the ideal formulary evaluation process.

Cephalosporins↗
PubMed1993

Pharmacy practice acts: a five-year follow-up.

OBJECTIVE: To rereview the status of state pharmacy practice acts since 1987. Additionally, this report discusses adoption of the 1992 National Association of Boards of Pharmacy Model State Pharmacy Practice Act as the standard state pharmacy practice statute. DATA SOURCES: State codes for 50 states and the District of Columbia, with attention focused on the pharmacy practice acts; Puerto Rico and the Virgin Islands were excluded. CASE LAW SELECTION: Case law utilizing state pharmacy statutes was selected to demonstrate pharmacists' liability. DATA EXTRACTION: The focus on each statute was the statutory definition of the "practice of pharmacy." DATA SYNTHESIS: Twelve pharmacy laws (24 percent) contain no definition of the practice of pharmacy. Compounding (92 percent), dispensing (100 percent), interpretation and evaluation of prescriptions (72 percent), consultation (85 percent), drug utilization review (69 percent), drug product selection (54 percent), drug administration (21 percent), pharmacokinetic consultation and patient assessment (13 percent) were noted in the laws for the remaining 38 states and the District of Columbia. Significant pharmacy activities codified since 1987 include consultation, drug administration, pharmacokinetic consultation, and patient assessment. Statutes defining pharmacy practice impact the profession by affecting liability and by mirroring society's view of the role of the profession. CONCLUSIONS: States have enacted new statutes principally in the areas of progressive pharmacy practice functions since 1987. Enactment of the definition of professional practice contained in the National Association of Boards of Pharmacy Model State Pharmacy Practice Act would serve the pharmacy profession by: (1) creating a uniform professional purpose; (2) creating legal responsibility that reflects contemporary practice; (3) allowing pharmacists to enlarge the scope of their practice as the profession's societal role evolves; and (4) conserving revenues normally consumed by lobbying for constant legislative revisions.

Data Collection↗
PubMed2005

The strengths and limitations of meta-analyses based on aggregate data.

BACKGROUND: Properly performed systematic reviews and meta-analyses are thought by many to represent among the highest level of evidence addressing important clinical issues. Few would disagree that meta-analyses based on individual patient data (IPD) offer several advantages and represent the standard to which all other systematic reviews should be compared. METHODS: All cancer-related meta-analyses cited in Medline were classified as based on aggregate or individual patient data. A review was then undertaken of all reports comparing the comparative strengths and limitations of meta-analyses using either aggregate or individual patient data. RESULTS: The majority of published meta-analyses are based on summary or aggregate patient data (APD). Reasons suggested for this include the considerable resources, years of study and often, broad international cooperation required for IPD meta-analyses. Many of the most important features of systematic reviews including formal meta-analyses are addressed by both IPD and APD meta-analyses. The need for defining an explicit and relevant clinical question, exhaustively searching for the totality of evidence, meticulous and unbiased data transfer or extraction, assessment of between study heterogeneity and the use of appropriate statistical methods for estimating summary effect measures are essentially the same for the two approaches. CONCLUSION: IPD offers advantages and, when feasible, should be considered the best opportunity to summarize the results of multiple studies. However, the resources, time and cooperation required for such studies will continue to limit their use in many important areas of clinical medicine which can be meaningfully and cost-effectively approached by properly performed APD meta-analyses. APD meta-analyses continue to be the mainstay of systematic reviews utilized by the US Preventive Services Task Force, the Cochrane Collaboration and many professional societies to support clinical practice guidelines.

Bias↗
PubMed1990

Physician payment and cost-containment strategies in West Germany: suggestions for Medicare reform.

The West German health care system pays ambulatory care physicians on a fee-for-service basis but employs a national relative value scale and regional capitation-based revenue pools to achieve expenditure controls on total physician reimbursement. Physician-controlled organizations manage these pools and conduct utilization reviews on their own members. The capitation rates are determined by negotiations between the physician associations and health insurers. The West German government has been able to exert some influence on the outcome of these negotiations through a quasi-governmental advisory body. Aspects of this structure could be adopted by Medicare in order to determine conversion factors for resource-based relative value scales or to create expenditure control and incentive structures for Medicare-participating physicians.

Ambulatory Care↗
PubMed1992

HMOs for Medicaid: the road to financial independence is often poorly paved.

During the 1980s both the federal government and the private sector articulated policies to encourage the development and participation of health maintenance organizations (HMOs) in the Medicaid program. However, the policies, intended to save costs, limited the ability of new HMOs to achieve financial independence. New plans that emphasize Medicaid participation have few, if any, options on benefit design or in setting capitation rates. Relative to fee-for-service Medicaid programs, their costs to provide services may be quite high, as they have neither the buying power not the ability to impose discounts. As a consequence, plans must focus their financial planning efforts on targeting and attaining a stable enrollment base and on controlling the amount of services provided, tasks that are difficult for all HMOs. Achieving a stable enrollment base is particularly hard because Medicaid eligibles have few incentives to enroll and once enrolled often lose their Medicaid eligibility. Traditional HMOs control the amount of services provided through physician selection, financial incentives on physicians, and monitoring and utilization review. Lack of information and the difficulty inherent in attracting sufficient provider participation limit the first two strategies, so new plans often adopt organization structures that rely heavily on monitoring activities. Unfortunately, management information systems for HMOs are often the weakest link. We discuss the tasks and present data on financial planning, on putting financial plans into operation, and on monitoring progress toward financial independence for a set of ten demonstration projects sponsored by the Robert Wood Johnson Foundation.

Cost Control↗
PubMed1977

The effect of physician-controlled health insurance. U.S. v. Oregon State Medical Society.

The trial record in an antitrust case against the Oregon State Medical Society, finally decided in 1952, was examined to reconstruct the behavior of a competitive market for health insurance coverage. Health insurers, called "hospital associations," were found to have engaged individually in cost-control efforts similar to, but possibly more aggressive than, today's utilization review under professional sponsorship. The subsequent disappearance of these insurer-initiated cost controls in Oregon is traced to the medical society's organization of a competing Blue Shield plan as a model of insurer conduct and to a simultaneous boycott by physicians of the hospital associations as long as they persisted in questioning doctors' practices. Some modern parallels are noted, and the advantages of fostering privately sponsored cost-control efforts are suggested.

Hospitals↗
PubMedDate not supplied

Clinical features of early HIV in the Edinburgh City Hospital cohort.

In order to describe the clinical features of HIV (non-AIDS), particularly injection drug use (IDU) related HIV, in patients attending the Regional Infectious Diseases Unit in Edinburgh, a prospective review utilizing the WHO staging system of the 680 HIV positive patients, 30% of whom were women and 68% were infected via IDU, was undertaken. Despite the fact that the majority of drug users and heterosexuals enrolled asymptomatic, by 1993, 71% of the patients had developed some HIV related clinical problem. The important clinical problems observed for the cohort were; minor skin problems, minor bacterial infections, major bacterial sepsis, oral thrush, oral hairy leucoplakia, significant weight loss of > 10%, HIV related thrombocytopenia and of course AIDS. Unlike previous reports from other areas, in Edinburgh drug users were not more likely than other risk groups to develop severe bacterial disease. Differences in morbidity and mortality rates by risk group but not by gender were noted but these may well be affected by the very different enrolment pattern observed in the various risk groups. The pre-AIDS mortality rates for drug users were remarkably similar to published rates from other centres.

Cohort Studies↗
PubMed1995

The evolution of social work in a community hospital.

Since 1905 social work has had the privilege of working with great medical leaders who have respected and assisted our profession. As predicted in 1984 by Abraham Lurie, The social work department of the future will be more decentralized ... develop stronger links administratively ... knowledge of changing social problems ... legislation, research, computerization, data gathering and retrieval. The Columbus Regional Hospital Social Work department is still early in its development, yet the above predictors have occurred which strengthened social work role and professional practice. By 1992 the following areas served as a strong foundation for the department's continued growth: Resource acquisition Hospital Integration Physician Support We must continue to advocate for improved care along with providing an environment of compassion for the patients and their families who seek services. Through continued participation on hospital committees such as ethics, and utilization review, we can demonstrate our practice and influence the environment. By creatively accessing resources we can influence and shape opportunities for colleagues. As a social work manager I thank those who have come before me who laid framework, fought battles and defined territory. We need to continue to support one another through collaborative processes and shared experiential learnings.

Community-Institutional Relations↗