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PubMed2003

Examining diabetes health benefits in health plans of large employers.

Components of the contract specifications (also known as model purchasing specifications) for diabetes care that were developed by George Washington University (Washington, D.C.) and the Centers for Disease Control and Prevention were applied to 20 health plans from two Fortune 500 companies as well as the Federal Employee Health Benefits Plan to investigate the extent of diabetes-related benefits available to employees. Diabetes-related benefits covered a range of services and supplies that include insulin, physician visits, immunizations, diabetes preventive assessments, foot and eye exams, hemoglobin A1c tests, orthotics, diabetes self-management education, case management, smoking cessation, obesity treatment, and exercise training. The 20 health plans included health maintenance organizations, preferred provider organizations, point of service plans, and one indemnity plan. Services and supplies were assigned to three tiers: tier 1, general diabetes care; tier 2, specialty diabetes care; tier 3, lifestyle services. Services and supplies were considered covered even if they required authorization by the provider (e.g., doctor referral, recommendation, or prescription) or the health plan. Tier 1 services and supplies received more comprehensive coverage by all health plans. Differences in coverage were more notable in tiers 2 and 3 than in tier 1. Tier 3 (lifestyle services) received less coverage than tiers 1 and 2.

Contract Services↗
PubMed2006

Payer type has little effect on operative rate and surgeons' work intensity.

Does health-care payer type affect the rate of operative treatment and surgeons' work intensity for patients with orthopaedic conditions? We analyzed the clinical and financial data collected during 6 consecutive years (1999-2004) for a group practice of 40 orthopaedic surgeons. We examined the rate of operative treatment and surgeons' work intensity (total physician's work Resource-based Relative Value System units) by diagnosis, patient age, and payer type. The eight payer types were: capitation health maintenance organization, health maintenance organization, preferred provider organization, indemnity, self-pay, Workers' Compensation, Medicaid, and Medicare. There were 230,306 patients with 526 unique primary diagnoses. Diagnosis accounted for most of the variability in operative rates and surgeons' work intensity. After adjusting for differences attributable to diagnosis, payer type had little effect on the rate of operative treatment and surgeons' work intensity.

Adult↗
PubMed2003

Association between insurance status and admission rate for patients evaluated in the emergency department.

OBJECTIVES: To determine if differences exist in hospital and intensive care unit (ICU)/operating room admission rates based on health insurance status. METHODS: This was a retrospective, cross-sectional study of data from hospital clinical and financial records for all 2001 emergency department (ED) visits (80,209) to an academic urban hospital. Hospital admission and intensive care unit (ICU)/operating room admissions were analyzed, controlling for triage acuity, primary complaint, diagnosis, diagnosis-related group (DRG) severity, and demographics. Multivariate logistic regression models identified factors associated with hospital admission for under insured (self-pay and Medicaid) compared with other insured (private health maintenance organization, preferred provider organization, worker's compensation, and Medicare) patients. RESULTS: Compared with the other insured group, under insured patients were less likely, overall, to be admitted to the hospital (odds ratio [OR], 0.82; 95% CI = 0.76 to 0.90), controlling for all other factors studied. Subgroup analysis of common complaints showed under insured patients with a chief complaint of abdominal pain (OR, 0.67; 95% CI = 0.55 to 0.80) or headache (OR, 0.61; 95% CI = 0.39 to 0.95) had the lowest adjusted ORs for admission to the hospital, compared with other insured patients. Under insured patients with DRG of "menstrual and other female reproductive system disorders" (OR, 0.17; 95% CI = 0.06 to 0.51) or "esophagitis, gastroenteritis, and miscellaneous digestive disorders" (OR, 0.55; 95% CI = 0.28 to 0.96) also were less likely to be admitted compared with the other insured group. No significant differences in ICU/operating room admission rates were found between insurance groups. CONCLUSIONS: Whereas there was no difference in admission rates to the ICU/operating room by insurance status, this single-center study does suggest an association between insurance status and admission to a general hospital service, which may or may not be causally related. Factors other than provider bias may be responsible for this observed difference.

Adult↗
PubMed1994

The challenge of managed care and managed competition.

Payment for health care in the United States changed rapidly during the 1980s, with the changes often identified by three-letter acronyms such as HMO, PPO, DRG, and RVS (health maintenance organization, preferred provider organization, diagnosis-related group, and relative value system). Changes are likely to be even more rapid and fundamental in the next few years. "Managed care" and "managed competition" are the principal terms being used to describe these pending changes. In this paper, we briefly present the problems that have led to changes, the changes that have occurred, the changes likely in the future, the implications of these changes for radiologists, and how radiologists can respond most effectively. We concentrate on the implications of changes for radiologists and on how radiologists can respond effectively.

Competitive Medical Plans↗
PubMedDate not supplied

Important points in managed care contracts.

Health care is increasingly managed through some contractual relationship. Such contracts vary and the contracting entities may be clinics, universities, health maintenance organizations, individual practitioner organizations, preferred provider organizations, corporate health plans, or other structures. It is estimated that within 10 years more than 70 percent of all health care will be provided through some type of managed care plan.

Contract Services↗
PubMed1995

For the times they are a-changin'.

Today, as we deal with managed care, vertical integration, mergers, new technologies, diagnosis related groups, stockless or just-in-time distribution, capitated contracts, consignment, health maintenance organizations, preferred provider organizations, total quality management/continuous quality improvement, reengineering, federal regulations, care mapping, patient focused care, and so forth, it is obvious that the only thing that is constant is change. "For the times they are a changin."

Computer User Training↗
PubMed1990

How to evaluate managed care contracts.

In the early days of managed care, some hospitals hastily agreed to health plan contracts without proper deliberations. An analysis model can be used to examine the results of current managed care contracts and to estimate a proposed contract's potential bottom line contribution or opportunity loss. With this information, healthcare organizations can identify new contract proposals worth pursuing with health maintenance organizations, preferred provider organizations, employer groups, and other health plans.

Contract Services↗
PubMedDate not supplied

Healthcare pay: belts tighten--but who feels the squeeze?

A CEO of a renowned acute care facility echoes what many in the healthcare industry are experiencing: "At no time in my memory are we changing so much so fast ... with so little time in which to make changes." The once mighty fortress of the healthcare industry has been invaded by a Trojan horse: managed care. Consequently, managed care has become the primary impetus for industry change. Managed care penetration has increased dramatically over the past few years, and all indications point to its continued growth throughout the US. In 1995, 71% of employees covered under an employer-sponsored health plan received their care through a managed care arrangement (health maintenance organization, preferred provider organization, point of service plan) and only 29% were covered under a traditional indemnity plan. In contrast, 52% of employees had indemnity plans in 1992. Managed care is growing in the public sector as well. Government-sponsored programs such as Medicare and Medicaid increasingly rely on managed care to help control costs and utilization. Though Medicare managed care enrollment today represents only about 10% of the Medicare population, enrollment has more than doubled between 1990 and 1995. Almost every state has some form of Medicaid managed care program in place. Fifteen states have received waivers to mandate that recipients receive care through managed care arrangements, and an additional ten states await federal approval to do the same. Between the years 1993-95, the number of Medicaid beneficiaries enrolled in managed care plans increased 140% to a national enrollment of close to 12 million. In addition to factors in the healthcare field such as uncompensated care, increased outpatient services, excess bed capacity, and restrictions in government reimbursement, the shift to managed care has forced hospitals to find new ways to operate within the healthcare delivery system. In particular, because hospitals' human resource costs are a substantial portion of their budgets, compensation policies are an important component of managing the cost of day-to-day operations. The 1996 Coopers & Lybrand Compensation in the Healthcare Industry Survey summarizes the responses from 207 healthcare organizations, primarily hospitals, in terms of their efforts to survive this constantly changing environment. Respondents included acute care and specialty hospitals, community-based hospitals, academic medical centers, public, and private organizations. The survey addresses operational issues, compensation incentives, special pay, and other compensation-related programs. This article analyzes the results of the Coopers & Lybrand survey.

Cost Control↗
PubMed1998

Medicare Program; establishment of the Medicare+Choice Program--HCFA. Interim final rule with comment period.

The Balanced Budget Act of 1997 (BBA) establishes a new Medicare+Choice (M+C) program that significantly expands the health care options available to Medicare beneficiaries. Under this program, eligible individuals may elect to receive Medicare benefits through enrollment in one of an array of private health plan choices beyond the original Medicare program or the plans now available through managed care organizations under section 1876 of the Social Security Act. Among the alternatives that will be available to Medicare beneficiaries are M+C coordinated care plans (including plans offered by health maintenance organizations, preferred provider organizations, and provider-sponsored organizations), M+C "MSA" plans, that is, a combination of a high deductible M+C health insurance plan and a contribution to an M+C medical savings account (MSA), and M+C private fee-for-service plans. The introduction of the M+C program will have a profound effect on Medicare beneficiaries and on the health plans and providers that furnish care. The new provisions of the Medicare statute, set forth as Part C of title XVIII of the Social Security Act, address a wide range of areas, including eligibility and enrollment, benefits and beneficiary protections, quality assurance, participating providers, payments to M+C organizations, premiums, appeals and grievances, and contracting rules. This interim final rule explains and implements these provisions. In addition, we are soliciting letters of intent from organizations that intend to offer M+C MSA plans to Medicare beneficiaries and/or to serve as M+C MSA trustees.

Aged↗
PubMed2001

Consumer satisfaction with telehealth advice-nursing.

An increase in interest in the establishment of telephone advice services has resulted in the proliferation of call centers. Despite their wide usage, research for the most part has not addressed the quality of care in relation to consumer satisfaction. This paper examines consumer outcomes of satisfaction, and follow-up with recommendations, within a framework of the nursing process and its associated components of assessment (including problem identification), care planning, intervention, and evaluation. The data for the study were obtained from seven after-hours call centers operating under the auspices of health maintenance organizations, preferred provider organizations, and private insurance companies. A sample of 157 non-redundant telephone calls from adults with medical-surgical problems were audiotaped with providers' and callers' consent. Sociodemographic information of the advice nurses, and chief complaints of the callers were obtained. The quality of nursing of the audiotaped calls was rated through an implicit review method by registered nurse raters using an advice nurse structured implicit review (AN-SIR) form developed for the study. Follow-up information was obtained through telephone calls to ascertain the consumers' perceptions of satisfaction, helpfulness, and follow-through with recommendations. Results indicated that consumers calling with a variety of general complaints contacted 32 nurses in advice nurse call centers. The quality of nursing process was found to be the best in the area of intervention. Evaluation was also well above the midpoint on a transformed scale of zero to 100. Assessment, although slightly above midpoint, was the lowest of the three components of the nursing process examined. Consumer satisfaction was high with 95.4 percent of the consumers rating the calls as completely or at least somewhat satisfied, and 93.2 percent, stating the advice was very or somewhat helpful. Exploratory regression analysis showed that the component of intervention was significantly related to consumer satisfaction. The present study pioneers the way to rate the quality of the advice nurses' interactions with consumers, and lays the groundwork for further investigations of health care provider behavior and consumer outcomes. Further studies are recommended to investigate predictors of consumer satisfaction, and cost-benefit in terms of consumer expenditures of time, funds, and energy.

Adult↗
PubMed2002

Managed care plans' requirements for screening for alcohol, drug, and mental health problems in primary care.

OBJECTIVE: To determine managed care organizations' (MCOs) requirements for screening for alcohol, drug, or mental health problems in primary care settings. STUDY DESIGN: A telephone survey was used to gather information on the 3 largest commercial products offered by MCOs. Products included health maintenance organizations, preferred provider organizations, and point-of-service plans. METHODS: Managed care organizations were asked whether their products required screening for alcohol, drug, or mental health problems in primary care settings. Chi-square tests were performed to ascertain whether screening requirements, the distribution of practice guidelines, and the topics addressed in those guidelines varied by product type and contracting with specialty behavioral health vendors. The data were weighted to produce national estimates. RESULTS: Only 14.9% of the products surveyed required any alcohol, drug, or mental health screening by primary care practitioners. Slightly more than half of all the products surveyed distributed practice guidelines that addressed mental illness, and about one third distributed substance abuse practice guidelines. CONCLUSIONS: Although the feasibility, utility, and effectiveness of screening are increasingly recognized, few MCOs currently require alcohol, drug, or mental health screening by primary care physicians in any of their product types.

Health Care Surveys↗
PubMed1986

Medical screening and biological monitoring for the effects of exposure in the workplace. Review of 30 years of screening practices.

Increasingly larger proportions of our population are insured against health care costs through negotiated or mandated contracts involving active and retired workers and their dependents. Seeking to control and contain the dramatically rising costs, employers have begun ti demand full accountability from their third-party payers, in response to which the health care services delivery system is evolving health maintenance organizations, preferred provider organizations, independent practice associations, and variant aggregates of participants with more homogeneously predictable utilization rates and cost estimates. The resultant information base generates employer-specific data leading to earlier detection and identification of work-related and total premorbidity and morbidity, causing renewed emphasis on prevention through total, including work-site related, risk-factors reduction. The screening technology required for the implementation and evaluation of health risks assessment and reduction programs is reviewed. The technology has matured significantly over the past 30 years. Problem areas and action needs are identified.

Health Benefit Plans, Employee↗
PubMed1993

State Society expands managed care services.

All indicators surrounding the Clinton health care package point in one direction: managed care. But managed care, already a reality for many physicians involved in health maintenance organizations, preferred provider organizations, and point-of-service networks, has a myriad of meanings and facets. The Society is looking at every possible means to help members in these changing times.

Health Care Reform↗
PubMed1998

Trends in health care practitioner credentialing.

Once a risk management process limited to hospitals, the practice of practitioner credentialing has expanded to include many other health care organizations, including insurers, health maintenance organizations, preferred provider organizations, management services organizations, medical groups, and independent practice associations. Standards set by recognized accreditation bodies, including the Joint Commission on Accreditation of Healthcare Organizations (Joint Commission), National Committee for Quality Assurance (NCQA), and American Accreditation Health Care Commission/Utilization Review Accreditation Committee mandate a substantial effort to properly evaluate the credentials of health care practitioners. A sector of commerce called the credentials verification organization (CVO) industry has undertaken the mission to make the process of practitioner credentialing more consistent and efficient, faster, and less expensive.

Cost-Benefit Analysis↗
PubMed2000

A survey of participation in managed care programs by endodontic specialists.

A survey was published in the Quarterly Survey of Dental Practice (QSDP) Special Topics that dealt with contractual agreements in dentistry. This survey evaluated general dental practitioner participation apart from that of dental specialists in general. The Quarterly Survey of Dental Practice survey was modified and used in the present study to specifically determine the participation by endodontists in various contractual insurance agreements, including Preferred Provider Organization and Health Maintenance Organization programs. A 10% sample of practicing endodontists was randomly selected to participate in this survey. Questionnaires (331) were sent out, and 229 or 69% were returned. Total participation by endodontists responding to this survey in any Health Maintenance Organization and/or Preferred Provider Organization insurance plans was 31.3%; however the total percentage of patients treated under these insurance plans was only 6.6%. These results were similar to those in the 1994 survey in which it was shown that 27% of the general dental practitioners and 41% of the dental specialists participated in one or more of these insurance programs and treated respectively, 5% and 9%, of their patients under these plans. Although participation in various managed care programs by endodontists in this survey was close to one-third, the total number of patients treated under these plans was low. Overall patients treated under fee-for-service arrangements by endodontists responding to this survey formed 85.3% of their patient pool. It does not appear from the results of this survey that managed care insurance has a significant impact on the practice of endodontics. It can be postulated that endodontists are unwilling to accept more than a small reduction in fees to join managed care plans, and they also desire to retain full control of their dental practice.

Analysis of Variance↗
PubMedDate not supplied

HMOs and PPOs. How do they stack up?

Decisions on participation in health maintenance organization and preferred provider organization opportunities have become an essential responsibility for medical groups. In this practical guide, a clear framework for evaluating HMO and PPO programs from the perspective of the individual group practice is offered. A helpful series of figures outlines essential considerations concerning group goals and characteristics, the preliminary evaluating and detailed plan analysis phases, and contractual provisions.

Decision Making↗
PubMed1989

Alternate delivery systems.

Alternate delivery systems have made significant inroads in the delivery of health care services in the United States. The emergence of health maintenance organizations (HMOs), preferred provider organizations (PPOs) and other integrated delivery systems have changed the way patients and providers relate to each other. This paper reviews the various types of alternate delivery systems and discusses issues of concern to optometrists who wish to participate in these plans.

Delivery of Health Care↗
PubMed1996

Medicare and state health care programs: fraud and abuse; safe harbors for protecting health plans--Office of Inspector General, HHS. Final rule.

In accordance with section 14 of the Medicare and Medicaid Patient and Program Protection Act of 1987, this final rule sets forth various standards and guidelines for safe harbor provisions designed to protect certain health care plans, such as health maintenance organizations and preferred provider organizations, under the Medicare and State health care programs' anti-kickback statute. These safe harbor provisions were originally published in the Federal Register on November 5, 1992 in interim final form. In response to the various public comments received, this final rule revises and clarifies various aspects of that earlier rulemaking.

Fraud↗