[Clinical indications and risks of fresh frozen plasma (consensus conference). General Subdirectorate of Health Planning. Ministry of Health and Consumption, Madrid].
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Humans↗
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Quality management practices in Medicaid managed care: a national survey of Medicaid and commercial health plans participating in the Medicaid program.
CONTEXT: Rapid expansion of Medicaid managed care has raised concerns about the capacity and willingness of health plans enrolling Medicaid beneficiaries to provide high-quality care. Recently, legislation has facilitated market entry of Medicaid plans, health plans that draw most of their enrollment from the Medicaid population. OBJECTIVE: To characterize and compare the organizational characteristics and programs related to quality of care of commercial and Medicaid health plans that participate in the Medicaid program. DESIGN: Cross-sectional survey conducted September 1997 to April 1998. SETTING: The Medicaid program in 11 states and the District of Columbia. PARTICIPANTS: All 154 health plans in these localities that provided prepaid general medical care to Medicaid beneficiaries during June 1997, of which 130 (84%) responded to the survey. MAIN OUTCOME MEASURES: Health plan reports of structural characteristics, services offered, performance measurement and feedback, disease management programs, information systems capabilities, and provider network composition and relationships. RESULTS: Half of the respondents were Medicaid plans, with 75% or more of enrollees drawn from the Medicaid population. Medicaid plans tended to be smaller and newer than commercial plans that also served the Medicaid population and had more enabling programs targeting the special needs of the Medicaid population, such as inadequate transportation (85% of Medicaid plans vs 62% of commercial plans; P = .003) and illiteracy (66% vs 38%, respectively; P = .002). Overall, 71% of Medicaid plans vs 43% of commercial plans had enabling programs targeted at 6 or more of the 8 special needs we specified (P = .001). While commercial plans had a higher proportion of board-certified primary care physicians (81% vs 73%; P = .01), we found no major differences between Medicaid plans and commercial plans in collection and dissemination of performance measures, designation of specific areas for quality improvement, or use of disease management programs targeted at conditions prevalent in the Medicaid population. Neither commercial nor Medicaid plans reported high success in improving quality of care. CONCLUSIONS: Based on our survey, while Medicaid plans resemble commercial plans serving the Medicaid population in many aspects of quality management, they are more likely to target programs directed to the specific needs of the Medicaid population. Neither commercial nor Medicaid plans have notably strong records in actual quality improvement.
Certification↗
Features of employment-based health plans.
This Issue Brief focuses on changes to the health care financing and delivery system as implemented by employers. It discusses health plan costs, cost sharing, plan funding, health care delivery systems, services covered under various health plan types, coverage limitations, and retiree health coverage. National health expenditures are estimated at $1.035 trillion, representing 13.6 percent of Gross Domestic Product in 1996, up from $699.5 billion and 12.2 percent in 1990. Rising health care spending is also evident at the employer level: In 1996, employer spending on private health insurance totaled $262.7 billion, up from $61.0 billion in 1980. Business health spending as a percentage of total compensation increased from 3.7 percent in 1980 to a high of 6.6 percent in 1993, and declined to 5.9 percent in 1996. Employment-based health plans are the most common source of health insurance coverage among the nonelderly population in the United States, providing coverage to nearly two-thirds of those under age 65. Despite the growth of many cost-sharing provisions, individuals are paying a smaller percentage of total health care costs. In 1960, 69 percent of private health care expenditures were paid out of pocket. Between 1993 and 1996, only 37 percent of private health expenditures were paid out of pocket. One of the most significant developments of the 1980s, which has continued throughout the 1990s, is the growth of managed care plans. As recently as 1994, traditional indemnity plans were the most commonly offered type of employment-based health plan. As fewer employers offered traditional indemnity plans, participation in these plans declined and participation in managed care plans increased. In 1997, 15 percent of employees participating in a health plan were enrolled in an indemnity plan, compared with 52 percent in 1992. Since 1993, employment-based health benefit cost inflation has been virtually nonexistent. Employers have kept cost increases low by using managed care and making other changes. Workers have been shifted to, have been induced to choose, or have voluntarily selected managed care health plans. Preferred provider organization (PPO) and point-of-service (POS) plans have experienced relatively strong gains in enrollment. Employers have also increased the use of utilization review for active workers, and cut back on health benefits for retirees. These changes are in stark contrast to the pre-1993 period, which saw even faster change, with rising health care costs and increasing deductibles and coinsurance for workers in non-HMOs.
Cost Sharing↗
Observations on potential contributions of health planning.
The passage of the National Health Planning and Resources Development Act in the United States in 1974 is used to set the context for a new assessment of health planning as a change agent. In reviewing the record of health planning the most striking conclusion is that even its friends have been unable to establish that it has had any quantifiable impact. The authors suggest, however, that comprehensive health planning may have stimulated the belief that changes in medical care organization are crucial to improving the health care system. The authors next consider the role of health planning inferred from three widely espoused "models" of the health care system: professional, central planning, and market. Although market advocates generally deemphasize health planning as contrasted to those supporting a centrally planned system, none of the models is sufficiently developed to indicate specific roles and functions fro health planning. Basing their argument on goals for health care reform generally espoused by students of medical care organization, the authors assert that health planning agenices will be most effective if they are organizationally linked to general-purpose governments, encourage the formation of Health Maintenance Organizations, consciously involve themselves in health system reorganization, and design their policies so they can be effectively evaluated.
Community Participation↗
The ethical dilemmas of the Oregon health plan.
Escalating health care costs place our country at an economic disadvantage in the world marketplace. Currently, a mixture of rationing methods in the health care system limits access to control costs. Federal and state moneys fund the state Medicaid programs. States on limited budgets often tighten eligibility to far below the poverty level; those with benefits get unlimited care and those without get none. The state of Oregon has a different idea: Medicaid covers everyone below the poverty level but limits services to those with the "best cost-to-benefit ratio." Many people consider the distribution and finance of health care an ethical issue. The Oregon plan raises some ethical concerns and several arguments. The federal government waived Title XIX of the Social Security Act to allow implementation of the plan. Many providers believe universal access is important; however, the drive to see more patients may limit visit time.
Decision Making, Organizational↗
The Oregon Health Plan.
The Oregon Health Plan is an innovative approach to providing a basic level of health care coverage for all citizens. A major component of the plan provides for prevention of illness. True, there is rationing of health care in the plan, but without such a plan the uninsured are currently limited in access to care. The plan may be flawed, but this cannot be known until it has been tried and monitored. The reality is that health care dollars are diminishing, and alternative approaches to health care are going to have to be investigated. This plan is truly a starting point for the development of a national health care policy. Let us hope that the federal government will allow Oregon to begin this bold experiment, and perhaps benefit the disenfranchised in this country.
Humans↗
Disease management practices of health plans.
OBJECTIVE: To investigate how health plans manage chronic diseases. STUDY DESIGN: Health plan medical directors were surveyed regarding the disease management (DM) practices of their plans. METHODS: We took a stratified random sample of 65 plans, all members of the American Association of Health Plans. Forty-five plans responded. Results were weighted to be representative of the industry (including nonmember plans). Medical directors were asked to consider that they had a DM program only if 2 things were true: (1) A majority of a plan's enrollees could not be ineligible for a DM program for non-clinical reasons (eg, geographic location); and (2) a DM program had to have at least 6 of the 8 components of a DM program as defined by the Disease Management Association of America. RESULTS: The 3 diseases most likely to be the focus of DM programs were diabetes, asthma, and congestive heart failure. For each of these diseases, at least one quarter of Americans were enrolled in plans offering a DM program. Medical directors perceived their DM programs to be highly effective in reducing mortality and morbidity and in improving the functional status of patients, and perceived them to be effective in lowering cost. The greatest challenge in implementing DM programs involves information technology. These results yield insights into the future of treatment of chronic disease in the United States. CONCLUSION: Health plans have made a significant investment in programs to improve care for chronic illness. The almost universality of DM programs highlight the need for scholarly evaluations of their effectiveness and cost effectiveness.
Asthma↗
Measures of community health status for health planning.
The National Health Planning and Resources Development Act of 1974 (P.L. 93-641) requires health systems agencies (HSAs) to assess the health status of their area populations but limits their data-collecting activity. Numerous measures of health status have been devised, but many of these require data that are not yet available or are available only on the national level. Proposed measures are reviewed, and the problems of applying them to the measurement of health status in small areas, under current technical and practical constraints, are discussed. Several measures have promise for giving reasonable results, but only with further development of data sources, estimation techniques, and social indicator models; under present constraints, HSAs will have to work with less precise and less useful methods.
Health Status Indicators↗
Health plan capitation strategy: do you have what it takes? What we're looking for as a health plan.
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California↗
Geographic variation of asthma quality measures within and between health plans.
OBJECTIVE: To contrast health plan performance in treating pediatric asthma within and between different geographic regions. STUDY DESIGN: Retrospective analysis of administrative claims data for 18 health plans serving Medicaid enrollees. METHODS: The study population was 3970 children 5-18 years old with persistent asthma who were continuously enrolled in the same Michigan Medicaid health plan for 2002 and 2003, with no other source of health insurance. Outcome measures were assessed based on national guidelines for asthma management: at least 1 asthma controller medication prescription, at least 1 outpatient visit, 1 or more asthma emergency department visits, and an annual influenza vaccination. RESULTS: Adherence to national guidelines varied significantly (P </= .05) between plans. The proportion of children with at least 1 asthma controller prescription ranged from 66% to 88%; the proportion of children with influenza vaccination ranged from 3% to 46%. Plan ranking varied depending on the guideline measure used. The plan with the lowest aggregate proportion of children who had asthma controller prescriptions (66%) had regional proportions that ranged widely, from 44% to 72%. Some plans were observed to rank highly in performance in 1 region and substantially lower in other regions; similar within-plan regional variation was found for each outcome measure. CONCLUSIONS: Assessments of adherence to Medicaid pediatric asthma management guidelines at the plan level may be insufficient to identify opportunities for improvement. Administrative claims-based profiles of plan performance that are sensitive to regional variations in plan characteristics may be particularly useful in isolating and prioritizing quality-improvement opportunities.
Adolescent↗
Up-to-date denominators: evaluation of taxation family file for public health planning.
Public Health agencies need up-to-date population data, and Statistics Canada's Taxation Family File (T1FF) database, developed annually from T1 personal income tax forms, may meet this need. We compared 1989 T1FF data for Ottawa-Carleton with census data. The overall population estimate for the region was 98% of the census figure. Equivalent figures were 94% for central cities, 98% for suburbs and 122% for rural areas. The T1FF underestimated the population of children (89%) and seniors (93%). Population estimates for smaller neighbourhoods were poorer, some being wrong by a factor of more than two. The errors are probably due to postal code conversion. The T1FF provides fairly accurate estimates of the population of larger areas, and can be much more current than census data. It is less accurate for smaller areas, offers a limited range of variables, does not specify gender for children, and is fairly expensive. Health units with a major commitment to needs-based planning should consider using the T1FF for denominator data, despite its limitations.
Canada↗
The effect of quality information on consumer health plan switching: evidence from the Buyers Health Care Action Group.
We examine the factors that lead employees to search for health plan quality information and the effect of such information on the decision to switch plans. Extending Hirshleifer and Riley's model [Hirshleifer, J., Riley, J.G., 1979. The analytics of uncertainty and information--an expositional survey. Journal of Economic Literature 17 (December (4)), 1375-1421] of the economics of information, we develop a two-equation model of quality information awareness and switching behavior. We estimate the model using data from a random sample of 651 single employees from 16 firms that are members of the Buyers Health Care Action Group, a health care purchasing coalition in the Minneapolis-St. Paul region. Our empirical results do not support either a link between quality information and switching behavior, or between perceived health plan satisfaction and switching. We do, however, find that switching is influenced by changes in premiums and whether an individual has an existing relationship with a health care provider.
Choice Behavior↗
Quality of care in for-profit and not-for-profit health plans enrolling Medicare beneficiaries.
BACKGROUND: For-profit health plans now enroll the majority of Medicare beneficiaries who select managed care. Prior research has produced conflicting results about whether for-profit health plans provide lower quality of care. OBJECTIVE: The objective was to compare the quality of care delivered by for-profit and not-for-profit health plans using Medicare Health Plan Employer Data and Information Set (HEDIS) clinical measures. RESEARCH DESIGN: This was an observational study comparing HEDIS scores in for-profit and not-for-profit health plans that enrolled Medicare beneficiaries in the United States during 1997. OUTCOME MEASURES: Outcome measures included health plan quality scores on each of 4 clinical services assessed by HEDIS: breast cancer screening, diabetic eye examination, beta-blocker medication after myocardial infarction, and follow-up after hospitalization for mental illness. RESULTS: The quality of care was lower in for-profit health plans than not-for-profit health plans on all 4 of the HEDIS measures we studied (67.5% vs 74.8% for breast cancer screening, 43.7% vs 57.7% for diabetic eye examination, 63.1% vs 75.2% for beta-blocker medication after myocardial infarction, and 42.1% vs 60.4% for follow-up after hospitalization for mental illness). Adjustment for sociodemographic case-mix and health plan characteristics reduced but did not eliminate the differences, which remained statistically significant for 3 of the 4 measures (not beta-blocker medication after myocardial infarction). Different geographic locations of for-profit and not-for-profit health plans did not explain these differences. CONCLUSION: By using standardized performance measures applied in a mandatory measurement program, we found that for-profit health plans provide lower quality of care than not-for-profit health plans. Special efforts to monitor and improve the quality of for-profit health plans may be warranted.
Aged↗
Comprehensive health planning. IV. The partnership for health programs.
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Community Health Services↗
A consumer-choice health plan for the 1990s. Universal health insurance in a system designed to promote quality and economy (1).
America's health care economy is a paradox of excess and deprivation. We spend more than 11 percent of the gross national product on health care, yet roughly 35 million Americans have no financial protection from medical expenses. To an increasing degree, the present financing system is inflationary, unfair, and wasteful. In its place we need a strategy that addresses the whole system, offers financial protection from health care expenses to all, and promotes the development of economical financing and delivery arrangements. Such a strategy must be designed to be broadly acceptable in our society. To remedy the deprivation, we propose that everyone not covered by Medicare, Medicaid, or some other public program be enabled to buy affordable coverage, either through their employers or through a "public sponsor." To attack the excess, we propose a strategy of managed competition in which collective agents, called sponsors, such as the Health Care Financing Administration and large employers, contract with competing health plans and manage a process of informed cost-conscious consumer choice that rewards providers who deliver high-quality care economically.
Centers for Medicare and Medicaid Services, U.S.↗
Health objectives and health system reform in Iowa: complementary approaches to health planning.
Current proposals for health system reform, such as that developed by the Iowa Leadership Consortium on Health care (ILC), call for the creation of agencies responsible for setting rates, monitoring quality and efficiency, and regulating capital investment. These can be described as health planning activities. However, it is planning of a very different nature than that conducted by community groups seeking to achieve the objectives of Healthy People 2000. Yet, despite their apparent differences, modern regulatory planning in the form proposed by the ILC and grass roots planning have at least the following in common: -Both seek to improve the efficiency of the health system in addressing health problems; -Both use population health status data as a basis for planning; -Both derive from a health planning tradition that focuses on restructuring the health care delivery system; -Both assume the legitimacy of the health care reform objectives relating to medical care; -Both may respond to community input regarding the nature of proposed reforms; and -Both may be criticized by radicals for railure to address the root, socioeconomic causes of disease.
Health Care Reform↗
John Kitzhaber and the Oregon Health Plan.
The Oregon Health Plan could not have developed into its current form without strong leadership. Criticism, which has shifted from the political left to the right, has been a constant companion, making integration of mental health services more precarious.
Health Care Reform↗
Health reform interrupted: the unraveling of the Oregon Health Plan.
The Oregon Health Plan (OHP) has received national and international attention for rationing medical care based on explicit priorities. However, in recent years OHP has lost substantial enrollment and struggled to live up to its core principles. This paper explores what went wrong in OHP and the implications of Oregon's experience for state-led health reform.
Health Care Rationing↗