Graduate program in managed care.
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Education, Nursing, Graduate↗
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Keys to success of BMT programs in managed care era.
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Bone Marrow Transplantation↗
Louisiana's ventilator assisted care program: case management services to link tertiary with community-based care.
The Ventilator Assisted Care Program has provided case management services to 36 youths and their families throughout Louisiana. It has served to link tertiary care centers with community-based service systems for the comprehensive care management of children and adolescents who use ventilators. The hospital-based, state-licensed service has been funded by Louisiana's Medicaid and Handicapped Children's Services Programs on a fee for service basis. It was originally funded by a grant from the Bureau of Maternal and Child Health. The service planning, coordination, and monitoring activities for individual families have usually begun predischarge and have been continued throughout the home care experience. The child and family have been considered to be the center of the care matrix, actively directing the service systems as well as service development.
Child↗
Economics of managed care in spinal cord injury.
OBJECTIVE: To determine and describe trends in economic variables related to the care of individuals with spinal cord injury (SCI) and significant changes in these trends coincident with major developments in medical care cost control. DATA SOURCES: Data from the National Spinal Cord Injury Statistical Center (NSCISC) database were used to review the economic trends in SCI management from 1973 to 1998 and their relation to managed care and other health care cost-containment measures. A panel of SCI health care specialists was interviewed to determine the appropriate data variables to be reviewed. The Shepherd Center Care Health Management Program, Atlanta, GA, is presented as an example of a fiscally successful managed care program for patients with SCI. DATA EXTRACTION: Data from the NSCISC database for the years studied were extracted and converted to a form suitable for analysis by means of the statistical software SAS. DATA SYNTHESIS: Statistical techniques included multiple regression analysis, logistic regression analysis, and model selection methods. CONCLUSIONS: Trends in economic variables, in the care of individuals with SCI show changes coincident with the introduction of Diagnostic Related Groups (DRGs) and managed care as models for provider reimbursement. Significant changes occurred in acute care charges, rehabilitation charges, length of stay, rehospitalization 1 year postinjury, time from injury to admission to a Model System, and discharges to a nursing home.
Cost Control↗
Patients' knowledge of health plan coverage and satisfaction with care.
OBJECTIVE: To test the hypothesis that patients' satisfaction with their healthcare is related to their knowledge of their managed care plan. STUDY DESIGN: A written survey was sent to beneficiaries of the military health system. PATIENTS AND METHODS: Respondents were active or retired military personnel and their nonmilitary, immediate family members enrolled in either TRICARE Prime, a voluntary, gatekeeper-based managed care program (enrollees), or other military managed care programs (nonenrollees). Responses to 5 questions that measured patients' understanding of their program served as independent variables; satisfaction with care was the dependent variable. Responses were stratified according to whether care was received in a military or a civilian healthcare organization. Analysis of variance (ANOVA) and regression analysis were used to determine the association between the variables. RESULTS: Enrollees differed from nonenrollees in certain sociodemographic characteristics, with nonenrollees being older (eta 2 = 0.035; P < .01), closer to retirement (eta 2 = 0.051; P < .01), and tending to receive healthcare in military healthcare organizations (HCO) (eta 2 = 0.009; P < .01). After controlling for sociodemographic characteristics, patients' understanding of their coverage served as a poor predictor (military HCO [R2 = 0.003; P < .01]; civilian HCO [R2 = 0.025; P < .01]) of satisfaction with their care. CONCLUSIONS: Patients' understanding of their coverage appears to be a statistically significant, but rather small, contributor to satisfaction with their care. The study suggests that health plan understanding is a poor predictor of patient satisfaction.
Adolescent↗
Quality improvement in Medicaid managed care: Experience of the best clinical and administrative practices initiative.
BACKGROUND: The Best Clinical and Administrative Practices (BCAP) initiative is part of the Medicaid Managed Care Program (MMCP) operated by the Center for Health Care Strategies. Work groups of 10-12 plans addressed quality of care in designated areas. METHODS AND INFORMATION SOURCES: The assessment of BCAP was part of a larger MMCP program evaluation funded by the Robert Wood Johnson Foundation. Case studies were developed for four BCAPs that focused respectively on improving birth outcomes, preventive care for children, asthma care, and care for adults with chronic illnesses or disabilities. They were based on document review and semistructured interviews. Medicaid managed care plans nationwide were also surveyed. FINDINGS: BCAP participants were overwhelmingly risk-based managed care plans whose enrollment was dominated by Medicaid. Participants said BCAP helped them enhance the way they approach quality improvement. As a result of work group participation, most plans made changes in their delivery of care, and more than half sustained and continued to build on these changes after the work group ended. DISCUSSION: BCAP participation helped Medicaid plans change the way they think about quality improvement and take sustainable steps to improve quality; the ultimate impact may be stronger once plans become more sophisticated users of such techniques.
Adult↗
State substance abuse and mental health managed care evaluation program.
The articles in this special section of the Journal of Behavioral Health Services & Research (30:1) present results from evaluations of publicly funded managed care initiatives for substance abuse and mental health treatment in Arizona, Iowa, Maryland, and Nebraska. This overview outlines the four managed care programs and summarizes the results from the studies. The evaluations used administrative data and suggest a continuing challenge to structure plans so that undesired deleterious effects associated with adverse selection are minimized. Successful plans balanced risk with limited revenues so that they permitted greater access to less intensive services. Shifts from inpatient services to outpatient care were noted in most states. Future evaluations might conduct patient interviews to examine the effectiveness and quality of services for mental health and substance abuse problems more closely.
Humans↗
The impact of managed mental health care on women.
By 1995, 108 million Americans were enrolled in managed care mental health programs. Managed care is likely to have a differential impact on women, as indicated by epidemiologic patterns, psychodynamic theory, and data from outcome and cost studies. The challenge of providing compassionate, confidential, and effective care within a budget can be solved by a combination of new treatment methods, better focused managed care interventions, and legislation.
Female↗
Diabetes managed care and clinical outcomes: the Harbor City, California Kaiser Permanente diabetes care system.
OBJECTIVE: To investigate diabetes clinical outcomes in a large patient population by comparing results of computer-supported team care to those of usual care. STUDY DESIGN: Patients enrolled in a diabetes care management program were tracked by a computerized system. Their subsequent healthcare outcomes were compared with those of usual-care patients and those of patients who had been discontinued from being managed in this program. PATIENTS AND METHODS: Screening rates for glycosylated hemoglobin (GHb), urinary protein, serum lipids, and glycemic and blood pressure control were compared between currently managed and usual-care patients. Hospital days and screening rates in a subset of the currently managed group, long-term managed patients, were compared with those of no longer managed patients. RESULTS: Screening rates for GHb, urinary protein, and serum lipids were higher in currently managed patients than in usual-care patients. Follow-up of initially elevated GHb in currently managed and usual-care patients showed an overall decrease in both groups. Follow-up of initially elevated blood pressure in currently managed patients showed a decrease in both mean systolic and mean diastolic measurements, while follow-up in usual-care patients showed no change in either mean systolic or mean diastolic measurements. Inpatient utilization for the long-term managed patients decreased between 1995 and 1997 and was lower in 1997 for this group than for no longer managed patients. Screening rates for GHb, urinary protein, and serum lipids were higher in the long-term managed patients than in the no longer managed patients. CONCLUSIONS: Computer-supported care management by a dedicated team appears to reduce the number of hospitalizations and improve screening rates and glycemic and blood pressure control.
Aged↗
Variation in pediatric asthma quality improvement programs by managed care plans.
Although asthma quality improvement (QI) programs are common, little is known about the scope and content of QI initiatives in managed care arrangements. The authors conducted a cross-sectional survey of all managed care plans in Michigan serving the pediatric Medicaid population. Using semi-structured interviews, they assessed the comprehensiveness of the asthma QI program regarding provider, allied health professional, pharmacy, and member services. Although all QI initiatives included some type of physician-directed component and patient-directed components, only half included allied health professionals and one quarter included pharmacy-directed components. Interactive physician continuing medical education was associated with plans whose members were concentrated in only 1 or 2 counties. The authors noted wide variation in content, format, inclusion of incentives, inclusion of other health professionals, and outcome goals. The variation in QI approaches by each of the managed care organizations suggests that there is a dearth of information on appropriate and cost-effective methods to improve pediatric asthma quality at the plan level.
Asthma↗
Program management and health care informatics: defining relationships.
The program management (PM) structure is a relatively well-known organizational model for hospitals. A variation of the matrix structure, it allows for an interdisciplinary team of health care providers to facilitate patient care delivery. However, providing such focused care results in a complex, highly information-dependent operational environment. To meet the information needs of such an environment, careful planning in selecting and implementing technology is required. Along with supporting patient care, the technology will also help in managing costs, human resources, quality and utilization, as well as in monitoring performance and outcomes measurement. Focusing specifically on the information technology environment, this article addresses health care informatics (the diverse categories of information and systems) needed to support clinical program managers, executives and others in a PM organization. Examples from both a university-affiliated and a community-based program managed hospital illustrate their approach to PM and information technology.
Decision Support Systems, Management↗
Rules of the game: how public policy affects local health care markets.
This paper explores the impact of public policy on local health care systems in a representative sample of twelve U.S. communities. Site visits conducted in those communities suggest that public policy is an important force that shapes health system change, for instance, by establishing the underlying "rules of the game" for private and public actors and by influencing the decisions of national and regional entities to enter and exit local markets. These dynamics are explored through a discussion of several key policy areas, including Medicaid and Medicare managed care programs, state regulation of managed care, regulation of providers' rates, certificate-of-need rules, and oversight of conversions from nonprofit to for-profit status.
Community Health Services↗
The early experience of a voluntary small group insurance program utilizing managed care plans.
HealthCare Group of Arizona (HCGA), a state-sponsored, voluntary health insurance purchasing program offering prepaid health plans to small businesses, became operational in 1988. This article summarizes the results from a wide-ranging evaluation of that program and discusses their implications. In general, enrollees were satisfied with their experience in their plans. HCGA did not appear to attract an adverse mix of health risks, and service utilization rates were consistent with HMO industry averages. However, these findings varied across health plans and the marketing approaches they adopted. Enrollment growth in HCGA has been steady, but premium subsidies may be necessary if HCGA is to substantially increase its enrollment of low-wage, uninsured workers.
Adolescent↗
Effect of managed care on emergency department use in an uninsured population.
STUDY OBJECTIVE: The use of managed care to decrease emergency department (ED) use has been reported with some success among Medicaid and insured populations. Our objective is to determine the effect of a managed care program (the "Program") for uninsured patients on their use of emergency, inpatient, and outpatient services. METHODS: This was a retrospective, observational study with 3 groups of patients at an urban, academic medical center: uninsured patients enrolled in the Program, uninsured patients not enrolled in the Program ("Uninsured"), and commercially insured ("Commercial") patients. All patients received services at least once annually during the 5-year study duration. Administrative databases provided data on ED visits, hospital discharges, hospital days, primary care visits, and specialty care visits during the preprogram and 4 postprogram years. RESULTS: There were 1,676 Program, 335 Uninsured, and 844 Commercial patients (2,855 total patients). Use of emergency, inpatient, and outpatient specialty clinics by all groups did not change significantly after program implementation. There was a modest increase in outpatient primary care use by Program members. CONCLUSION: Implementation of a managed care program did not significantly alter ED or inpatient hospital use patterns in an uninsured, indigent population. Providing a primary care provider and health care benefits alone was insufficient to reduce ED use in this population.
Academic Medical Centers↗
Federally funded sexually transmitted disease programs and managed care: a review of current and planned partnerships.
BACKGROUND: The Centers for Disease Control and Prevention requested that sexually transmitted disease (STD) programs report their current activities and plans to collaborate with managed care organizations in their 1999 applications for federal funding. GOAL: To review CDC STD program applications for funding to assess the number of activities between STD programs and managed care organizations. METHODS: Narrative data on managed care topics were abstracted from 59 funding applications (50 states, 7 cites or counties, and 2 US territories), using standard qualitative methods. A coding system was applied to categorize each managed care activity into one of nine categories (interrater reliability, 93%). An expert panel ranked activities by complexity, and these scores were used to develop an overall complexity score for each program. RESULTS: All but 9 of the 59 applicants reported managed care organization activities. Altogether, 208 activities were specifically documented, 45% of which were classified as operational in 1999. The most frequently reported activities involved gathering and giving information and promoting STD care through legislation and state Medicaid activities. CONCLUSIONS: Considerable information transfer and policy action between STD programs and managed care organizations are taking place. Further integration of services and policies should be studied and encouraged to promote the effective treatment of STD.
Centers for Disease Control and Prevention, U.S.↗
Medicaid capitation rates: methodological shortcomings and recommended solutions.
At both the federal and state level, managed care programs are considered one of the key solutions to the problem of containing costs in public sector health care programs, such as Medicaid; however, reimbursement issues need to be resolved before managed care programs can fully embrace public sector programs. Federal regulations require state Medicaid agencies to establish capitation rates that use fully documented actuarial methods that do not exceed the equivalent cost to the state for providing services to a like population. State agencies must also assure managed care programs that timely and reliable data is used, a sound actuarial method is employed, and the capitation rate is fair and equitable. Contractor confidence in a rate methodology will facilitate their participation in Medicaid. Reimbursement in managed care systems is usually based on some discount of the fee-for-service (FFS) equivalent capitation. Yet, state agencies differ in their ability to derive an accurate FFS capitation. This paper explores many of the methodological shortcomings common in using the FFS approach and offers some policy and technical solutions.
Actuarial Analysis↗
Evaluation of a faculty development program in managing care.
PURPOSE: To evaluate a faculty development program that teaches quality improvement and cost-effectiveness. METHOD: From October 2000 to February 2001, a two-part faculty development program was offered to 39 physicians from 19 U.S. medical schools supported by grants from the Partnerships for Quality Education (PQE) and Undergraduate Medical Education in the 21st Century (UME-21). Special features of the program included partnerships between academic and community physicians from each school, development of an educational innovation of interest to the participants, concurrent development of teaching skills and new medical knowledge, learning leadership skills (e.g., how to train colleagues to teach), and practice periods. The program focused on quality improvement and cost-effectiveness, but included other "managing care" topics. Prior to and after the course, participants assessed their knowledge of and competence to teach these topics, as well as other managing care topics. They also assessed their competence as medical educators and leaders. After the course, they indicated their progress in implementing their proposed educational innovations. RESULTS: Thirty-two of the 39 physicians completed evaluations both before and after the program. Self-assessed knowledge and competence to teach quality improvement and cost-effectiveness were significantly higher at the end of the course, as were all self-assessed teaching and leadership skills. The largest change scores occurred in assessments of competency to teach the new topics and to teach in new ways. Participants who implemented their innovations rated their competencies to teach quality improvement and cost-effectiveness higher than did non-implementers. CONCLUSION: Opportunities for faculty to learn how to teach a topic of stated importance to them, to practice what they have learned, and to work collaboratively with partners improved teaching skills.
Academic Medical Centers↗
High-risk patients identified before costs explode.
Some health plan members exhibit subtle signs that they are at high risk of incurring major medical costs months before they actually begin running up big bills. If these ticking time bombs can be identified, they can be brought into care management programs before their costs explode.
Cost Control↗