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At least 127 records · Page 7Linked to original sources
PubMed2001

Medicaid program; Medicaid managed care. Health Care Financing Administration (HCFA), HHS. Final rule with comment period.

This final rule with comment period amends the Medicaid regulations to implement provisions of the Balanced Budget Act of 1997 (BBA) that allow the States greater flexibility by permitting them to amend their State plan to require certain categories of Medicaid beneficiaries to enroll in managed care entities without obtaining waivers if beneficiary choice is provided; establish new beneficiary protections in areas such as quality assurance, grievance rights, and coverage of emergency services; eliminate certain requirements viewed by State agencies as impediments to the growth of managed care programs, such as the enrollment composition requirement, the right to disenroll without cause at any time, and the prohibition against enrollee cost-sharing. In addition, this final rule expands on regulatory beneficiary protections provided to enrollees of prepaid health plans (PHPs) by requiring that PHPs comply with specified BBA requirements that would not otherwise apply to PHPs.

Budgets↗
PubMed1998

Case management programs in primary care.

To review the impact of case management programs on health care resource use; their impact on patient satisfaction, quality of life, and functional status (patient-centered outcomes); and their cost-effectiveness, we reviewed the English language literature utilizing the following MEDLINE and HealthSTAR headings: case management, patient care planning, patient-centered care, disease management, care management, and managed care programs. Bibliographies of relevant articles were also reviewed. Only randomized controlled trials were included. Data were extracted manually from relevant publications and are presented descriptively because formal, quantitative methods were not applicable. Nine studies met our inclusion criteria. Of the seven studies examining case management's impact on health resource use, only two found a positive effect. Both successful programs targeted patients with specified disease conditions and care was supervised by a medical subspecialist. None of the programs targeting general disease conditions or supervised by generalists reported a positive effect. All six studies examining patient-centered outcomes reported a positive impact. These effects were unrelated to the patient's conditions or the study personnel. Both studies examining clinical parameters found a positive impact. Only three studies examined costs; all reported nonsignificant cost savings. While case management programs offer theoretical benefits, few examples of successful programs were found. Positive effect was related to disease condition and specialty training of study personnel. Patient-centered outcomes were often improved upon but at unknown cost. Further multisite clinical trials are needed to define case management's role in our future health care system.

Case Management↗
PubMedDate not supplied

A literature review of cardiovascular disease management programs in managed care populations.

OBJECTIVES: (1) To review the literature on cardiovascular disease management programs in managed care populations, (2) compare the rigor of the studies and their findings by disease state, and (3) posit directions for future research. SUMMARY: A total of 20 studies conducted in managed care populations were reviewed: 5 in patients with congestive heart failure (CHF), 9 in hypertensive patients, and 6 in hyperlipidemia and/or coronary artery disease (hyperlipidemia- CAD) patients. Management of CHF involved multifaceted programs that included the participation of multiple health care professionals, patient and physician education, promotion of intensive drug therapy and lifestyle modifications, and close patient monitoring. The most common CHF management strategies were case management and physician education, with an emphasis on close patient monitoring. Hypertension and hyperlipidemia-CAD intervention programs focused on chronic outpatient management and regular follow-up, with an emphasis on self-management skills. These programs were managed through regular and periodic interventions, including pharmacist-managed clinics and automated provider notices. Many of the studies employed "before-after" comparisons in the absence of a truly experimental design and posed significant limitations due to variations in the outcomes measured, lack of transparent disease severity stratification, and variation across types of managed care organizations. CONCLUSION: A number of cardiovascular disease management strategies in the literature reported promising results. Many of the multidisciplinary CHF disease management programs were more complex than were programs for hypertension and hyperlipidemia-CAD, due, at least in part, to the nature and severity of the disease. A lack of agreement on appropriate economic and clinical outcomes for evaluating the effectiveness of cardiovascular disease management strategies is readily apparent.

Cardiovascular Diseases↗
PubMed1991

Impact of a mandatory Medicaid case management program on prenatal care and birth outcomes. A retrospective analysis.

This study examined the impact of Philadelphia's mandatory Medicaid case management program (HealthPASS) on adequacy of prenatal care and birth outcomes among enrollees. A sample of 217 deliveries for HealthPASS patients at the Hospital of the University of Pennsylvania (HUP) during 1988 was compared with a matched sample of 1988 deliveries at HUP for whom the payor was Pennsylvania's traditional fee-for-service Medicaid program. Inpatient charts for all 434 subjects were abstracted for information on sociodemographic characteristics, substance use during pregnancy (cigarettes, alcohol, and drugs), course and extent of prenatal care, and birth outcomes including birth weight, gestational age, and mortality. No significant differences were detected between HealthPASS and Medicaid groups, suggesting that the mandatory managed care program neither improved nor impeded access to needed services. These results were not surprising in view of the fact that HealthPASS actually did little to change provider or patient behavior with respect to obstetrical care. Both the HealthPASS and Medicaid groups experienced low rates of adequate prenatal care (39%) and high rates of low birth weight (20%). Also disturbing was the finding that at least 46% of women smoked during pregnancy, at least 20% drank alcohol, and at least 17% used cocaine. These findings support the need for continued efforts to improve both access to, and content of, prenatal care for the urban poor.

Adolescent↗
PubMed1997

Pricing specialty carve-outs and disease management programs under managed care.

The drive toward improved efficiency and effectiveness in health care has spawned disease management programs to address the needs of patients with certain conditions. These programs parallel traditional case management programs in monitoring patients, but disease management differs from case management in early assessment of patient risk, with proactive clinical interventions and educational efforts. The most comprehensive programs include a coordinated delivery system that can be "carved out" from other health care benefits. Pricing disease management can benefit from the analysis of detailed, disease-specific and community-specific data from public or private sources.

Capitation Fee↗
PubMed2006

Evidence-based health benefits management: strategies to optimize antiretroviral medication adherence and outcomes in HIV/AIDS.

OBJECTIVE: To review how evidence-based principles can be applied to benefit design, specialty network management, and medication therapy management to successfully manage pharmaceutical benefits for patients infected with human immunodeficiency virus (HIV). SUMMARY: The most critical barrier to successfully managing HIV disease is suboptimal patient adherence to antiretroviral therapy. Managing HIV infection is unique in that the risk of treatment failure increases remarkably with even relatively minor lapses in patient adherence. The incremental cost of HIV treatment failure has been approximated at $26,000 per patient per year. Treatment failure, of course, also drives mortality related to HIV and acquired immunodeficiency syndrome (AIDS). Benefit design, specialty medication management strategies, and care management programs can be integrated to deliver high-quality, efficient care that optimizes clinical outcomes for populations of HIV-infected individuals. CONCLUSION: Managed care programs can be structured to provide HIV care that allows optimal patient adherence and clinical outcomes.

Antiretroviral Therapy, Highly Active↗
PubMedDate not supplied

Changes in managed care activity in outpatient substance abuse treatment organizations, 1995-2000.

Using nationally representative data from 1995 and 2000, this study examines trends in managed care penetration and activity among outpatient drug treatment organizations in the United States. Further, it investigates how managed care activity varies across different types of treatment providers and for public and private managed care programs. Overall, managed care activity has increased, with a greater proportion of units having managed care arrangements and a larger percentage of clients covered by managed care. In general, public managed care activity has increased and private managed care activity has decreased. Treatment providers report that they have fewer managed care arrangements, which may reflect consolidation in the managed behavioral care sector. Finally, growth in managed care among outpatient substance abuse treatment units affiliated with hospitals and mental health centers may signal a preference for providers that can effectively link substance abuse treatment with medical and social service provision, or, alternatively, that linkages with such organizations may provide the size necessary to assume the risks associated with managed care contracts.

Health Care Surveys↗
PubMed1996

Assuring quality of care for children with special needs in managed care organizations: roles for pediatricians.

Increasing numbers of children with special health care needs are enrolling in managed care programs. Although managed care may improve service coordination and use of primary care, it may also threaten health outcomes for these children by potentially decreasing access to the range of needed services, eroding progress in developing community-based service systems, and failing to assure quality of care. To date, few frameworks have been proposed to assess quality of care for this population of children in managed care organizations. In this article, we adapt the Institute of Medicine's definition of quality and identify six key components: content of service delivery systems, the nature of desired health outcomes, risks associated with service delivery, constraints of care, interpersonal dimensions, and attention to developmental issues. These components can be assessed at three levels: the individual, the health plan, and the community. Pediatricians and other child health professionals have critical roles to play in assuring that policies and practices within managed care organizations promote a high quality of care for this vulnerable population of children.

Child↗
PubMedDate not supplied

Tracking Medicaid managed care in rural communities: a fifty-state follow-up.

This study updates a 1997 study examining implementation of rural Medicaid managed care programs. Most states operate Medicaid managed care programs for their beneficiaries, but the types of programs vary across urban and rural settings. Over the past four years the number of rural counties covered by Medicaid managed care, including fully capitated programs, has grown, although primary care case management (PCCM) remains the predominant program type in rural areas. Health plan withdrawals from rural areas have led some states with rural capitated programs to provide financial incentives or develop alternative approaches, such as enhanced PCCM programs.

Budgets↗
PubMed2004

Assessing the need for a clinical COPD care program in a managed care organization.

BACKGROUND: Chronic obstructive pulmonary disease (COPD), a systemic inflammatory condition, is costly and often devastating to patient quality of life. COPD is also greatly underdiagnosed and often inappropriately treated. A managed care organization therefore evaluated whether a systemwide COPD clinical program within its organization may be appropriate. The organization examined the current prevalence, costs, and adherence to clinical treatment guidelines. OBJECTIVE: To identify the prevalence and costs of COPD within the managed care organization and to ascertain whether the condition could be better managed using a systemwide clinical program. CONCLUSION: Both diagnosis and treatment of COPD would likely be improved with a comprehensive clinical COPD care program that would include measuring outcomes, stratifying COPD patients by risk, and initiating disease state management efforts.

Disease Management↗
PubMed1998

The role of nutrition screening and intervention programs in managed care.

Nutrition screening and intervention programs provide managed care plans with an opportunity to meet the needs of the increasing Medicare risk population. Recently, representatives from various health plans came together to discuss program benefits as well as the best practices in the development and implementation of such programs to ensure successful outcomes. Through simple and cost-effective programs, health plans can improve member satisfaction, resource utilization, and the health status of their members.

Aged↗
PubMed1999

Managed care of children with special health care needs: the ABC Program.

Families of children voluntarily enrolled in a managed care program for children with special health care needs receiving SSI and Medicaid benefits and their case managers were surveyed regarding care satisfaction, quality, and access. Claims data were used to compare the cost and utilization of health care before and during program enrollment. Families rated health care quality improved in 43%, unchanged as "excellent" in 50% of cases. The care received was seen as more nearly complete and of higher quality when the provider was based in the hospital or the hospital's community clinics as compared with "private" community pediatricians. Hospitalization decreased, but no decrease in cost was demonstrated. A carefully planned and implemented managed care program can improve patient perception of quality among chronically ill children.

Child↗
PubMed2000

Medicaid and indigent care issue brief: Medicaid: managed care.

In an effort to reduce the high cost of fee-for-service health care, many states have implemented managed care into their Medicaid programs. Managed care has many forms, but the most traditional measures states adopt are fully capitated, partially capitated, or primary care case management (PCCM) programs. According to the Kaiser Commission on the Future of Medicaid, enrollment in Medicaid managed care has grown dramatically from 2.7 million beneficiaries in 1991 to 16.6 million in 1998. Over half (53.6 percent) of Medicaid beneficiaries, predominately poor children and their parents, are enrolled in some form of managed care.

Humans↗
PubMed2005

Asthma management programs in managed care organizations.

The aim of this work was to investigate how managed care organizations (MCOs) currently approach asthma treatment and management and to determine factors affecting asthma outcomes. A Web-based survey was administered to a national sample of 351 medical directors of MCOs to investigate the asthma management program components in their organizations as well as gaps and barriers in the management of patients with asthma. All 134 (38.2%) responding medical directors reported that their organizations monitor asthma patients. Plans use a variety of asthma management activities, including general member education (90%), member education by mail (87%), self-management education (85%), and provider education (82%). Educational resources (89%) and telephone advice nurse (77%) were the most common self-management strategies offered. Among factors impeding the provision of effective asthma care, noncompliance with asthma treatment, the inappropriate use of medications, and the need for multiple medications were cited by virtually all respondents. Health plans rely on an array of strategies to manage asthma patients. Education encouraging patient self-management is a key component of asthma management programs. However, a considerable number of treatment approach barriers are impeding the achievement of proper asthma care. Without innovative approaches to care, it appears that current MCOs' asthma management efforts may not result in substantial improvements in asthma outcomes.

Asthma↗
PubMed1996

Diabetes and managed care: the Lovelace Health System's Episode of Care Program.

In order to efficiently manage the care of large populations, the health of that population must be evaluated. People identified with chronic medical disorders, such as diabetes mellitus, should have their disease managed proactively in the most cost-effective manner across the continuum of care. Lovelace Health System has established an Episode of Care disease management program based on the principles of clinical practice improvement. The diabetes program is described as an example of this approach to define and monitor best practice and to decrease variation among providers. This approach optimizes the use of health care resources and improves patient outcomes.

Continuity of Patient Care↗