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New England's largest HMO wants to be even bigger. The product of a 1995 merger, Harvard Pilgrim is seeking ways to reduce per-member-per-month costs, creating new health plans with greater choice of providers, changing physician relationships from staff-model to group practice and looking at other merger opportunities.
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Expenditures for growth hormone (GH) in the United States approximates 400 million dollars annually. There is considerable controversy and variation around both the indications for GH treatment and insurance coverage decisions involving GH treatment. To address these issues, Harvard Community Health Plan (HCHP), now merged with Pilgrim Health Care to form Harvard Pilgrim Health Care (HPHC), developed a policy and implementation plan in 1992 which limited access to GH to those conditions for which GH has been shown to be effective. The 4-year experience of the HPHC Growth Hormone Review Committee, which determines by case review whether criteria for GH coverage are met, is described. The result has been a more rational, equitable approach to decisions about GH treatment coverage, and significant cost reductions. Caution is warranted in expanding access to GH because the potential for serious side effects has not been completely eliminated. Four years after the inception of the policy and approval process (1992-1995), it is estimated that savings have exceeded 1 million dollars. Growth hormone prescribing costs decreased from 13.4% of total to 4.4% of total drug costs 4 years after the new policy was implemented. This approach to policy development and implementation may be applicable to managing high-cost pharmaceuticals and advanced technology in other settings.
In disease surveillance, there are often many different data sets or data groupings for which we wish to do surveillance. If each data set is analysed separately rather than combined, the statistical power to detect an outbreak that is present in all data sets may suffer due to low numbers in each. On the other hand, if the data sets are added by taking the sum of the counts, then a signal that is primarily present in one data set may be hidden due to random noise in the other data sets. In this paper, we present an extension of the spatial and space-time scan statistic that simultaneously incorporates multiple data sets into a single likelihood function, so that a signal is generated whether it occurs in only one or in multiple data sets. This is done by defining the combined log likelihood as the sum of the individual log likelihoods for those data sets for which the observed case count is more than the expected. We also present another extension, where the concept of combining likelihoods from different data sets is used to adjust for covariates. Using data from the National Bioterrorism Syndromic Surveillance Demonstration Project, we illustrate the new method using physician telephone calls, regular physician visits and urgent care visits by Harvard Pilgrim Health Care members cared for by Harvard Vanguard Medical Associates, a large multi-specialty group practice in Massachusetts. For upper and lower gastrointestinal (GI) illness, there were on average 20 telephone calls, nine urgent care visits and 22 regular physician visits per day. The strongest signal was generated by a single data set and due to a familial outbreak of pinworm disease. The second and third strongest signals were generated by the combined strength of two of the three data sets.
BACKGROUND: Many managed care organizations use feedback based on electronically maintained claims data to alert physicians to potential treatment problems, including patient medication nonadherence. However, the efficacy of such interventions for improving adherence among patients treated for depression is unknown. METHODS: We examined an antidepressant compliance program consisting of faxed alerts to physicians beginning May 2003 using interrupted time series analysis to evaluate its impact on rates of antidepressant adherence between May 2002 and May 2004 among members of the managed care plan of Harvard Pilgrim Health Care, which is a health plan operating in 3 states in New England, with corporate headquarters in Wellesley, Mass. The program alerted prescribing physicians to patients with gaps of more than 10 days in refilling antidepressant prescriptions during the first 180 days of treatment. Our outcome measures were rates of nonadherence among patients with refill gaps of more than 10 days ("delayed refill") and proportion of days without treatment within the first 180 days of treatment. RESULTS: A total of 13 128 patients (> or = 18 years of age) who were starting treatment with antidepressants met the study criteria. Rates of nonadherence among patients with delayed refills remained constant (P = .22) over the 2-year study period, averaging 75% (95% confidence interval, 72.7%-77.3%). Rates of antidepressant nonadherence significantly increased over time (P = .04), with an average of 40% (95% confidence interval, 38.4%-41.6%) of days without dispensed antidepressants available during treatment episodes. CONCLUSIONS: Using real-time pharmacy information to alert physicians regarding patient adherence was not successful in increasing antidepressant adherence rates among members of the managed care plan. Effectiveness of electronically triggered, patient-specific, faxed feedback should be carefully evaluated before widespread implementation, because faxes are insufficient as a stand-alone policy tool.
The Massachusetts insurance commissioner placed Harvard Pilgrim Health Care (HPHC) in receivership in January on the basis of large projected losses that put the nonprofit plan in a significant negative net worth position. Because Harvard Pilgrim was the largest health plan in the market, with substantial amounts payable to hospitals and physicians, its financial problems shook the Boston health care community. The story also attracted national attention because of the plan's prominence and its reputation for quality. The Center for Studying Health System Change (HSC) followed the Harvard Pilgrim story closely as part of its continuous tracking of Boston--one of the 12 Community Tracking Study sites visited every two years--and is able to put this event in broader context. Many of Harvard Pilgrim's problems are evident in plans elsewhere. This Issue Brief discusses the causes of the plan's financial problem and the state's response, which has preserved the organization.
This article reviews the tension between "gatekeeping," routinely practiced by managed care to limit utilization of care and, presumably, cost, and the increased demands of purchasers (such as Medicaid), consumer groups, and the National Council for Quality Assurance for mental health screening, outreach, and access to specialty care, particularly for vulnerable populations. Using examples from Harvard Pilgrim Health Care in Boston, the second oldest health maintenance organization in the country, the argument is advanced that early detection, coordination with primary care, and readily available expert consultation actually diminish cost while reducing morbidity and improving satisfaction.
To cut costs and boost quality of care for seniors, try a SNF rounding program. Harvard Pilgrim Health Care Inc., based in Dedham, MA, is slashing Medicare inpatient bed days per 1,000 by helping its providers set up programs designed to avoid and substitute hospitalizations with subacute stays.
The pros and cons of treating health care as a profit-making business got a lively airing in Boston May 16, when the Harvard School of Public Health's "Second Conference on Strategic Alliances in the Evolving Health Care Market" presented what was billed as a "Socratic panel." The moderator was Charles R. Nesson, J.D., a Harvard Law School professor of 30 years' standing whose knack for guiding lively discussions is well known to viewers of such Public Broadcasting Service series as "The Constitution: That Delicate Balance. "As one panelist mentioned, Boston was an interesting place for this conversation. With a large and eminent medical establishment consisting mostly of traditionally not-for-profit institutions, the metropolis of the only state carried in 1972 by liberal Presidential candidate George McGovern is in one sense a skeptical holdout against the wave of aggressive investment capitalism that has been sweeping the health care industry since the 1994 failure of the Clinton health plan. In another sense, though, managed care-heavy Boston is an innovative crucible of change, just like its dominant HMO, the not-for-profit but merger-minded Harvard Pilgrim Health Care. Both of these facets of Beantown's health care psychology could be discerned in the comments heard during the panel discussion. With the permission of the Harvard School of Public Health--and asking due indulgence for the limitations of tape-recording technology in a room often buzzing with amateur comment--MANAGED CARE is pleased to present selections from the discussion in the hope that they will shed light on the business of health care.
Cost pressures and changes in the health care environment pose ethical challenges and hard choices for patients, physicians, policymakers, and society. In 2000 and 2001, the American College of Physicians, with the Harvard Pilgrim Health Care Ethics Program, convened a working group of stakeholders--patients, physicians, and managed care representatives, along with medical ethicists--to develop a statement of ethics for managed care. The group explored the impact of a changing health care environment on patient-physician relationships and how to best apply the principles of professionalism in this environment. The statement that emerged offers guidance on preserving the patient-clinician relationship, patient rights and responsibilities, confidentiality and privacy, resource allocation and stewardship, the obligation of health plans to foster an ethical environment for the delivery of care, and the clinician's responsibility to individual patients, the community, and the public health, among other issues.
OBJECTIVE: Physician attitudes may be a key factor in effective managed care for older patients. We sought to explore physicians' views of the influence of health maintenance organization (HMO) policies on the care of their older patients. DESIGN: A self-administered one-page questionnaire consisting of questions about physician demographics, the impact of HMOs on physician practice, patient care, HMO policies, and respondents' personal use of managed health care plans. PARTICIPANTS: The survey was mailed to 838 randomly selected primary care physicians affiliated with two large, nonprofit, academically-oriented, Medicare HMOs in Massachusetts. RESULTS: Completed surveys were received from 516 of 797 eligible primary care physicians, affiliated with either Secure Horizons (Tufts Associated Health Plan) or First Seniority (Harvard Pilgrim Health Care). About half (55%) of the physician respondents reported they had sufficient time to spend with their older patients. Most (81%) respondents indicated that overall, patients aged 65 and older received either better care or no change in care after joining an HMO. The majority of physicians reported that HMO affiliation had increased the frequency with which they addressed geriatric issues with their older patients. There were several patterns of response that emerged with respect to beliefs about key HMO policies. CONCLUSIONS: The majority of physicians working in two nonprofit, academically oriented Medicare HMOs in Massachusetts believed that the overall quality of care that older patients received after joining an HMO either did not change or improved.
The tumultuous fall into receivership of Harvard Pilgrim Health Care, and its subsequent financial rise, has been well documented. One of the principal concerns in situations of financial upheaval is how to ensure that staff and customers maintain a positive attitude toward the troubled health plan. An insider at Harvard Pilgrim provides a glimpse at the steps that were taken to ensure high-quality customer service and to retain valuable staff.
We developed a tool for evaluating clinical information systems (CIS) by mapping a set of detailed functional requirements to specific elements of clinical scenarios. A team of primary care physicians, specialists, medical records professionals, and information systems staff defined detailed requirements for a new CIS at Harvard Pilgrim Health Care. The requirements were mapped to elements of clinical scenarios, which were provided to vendors for use in demonstrating their systems. Systems were rated as to how well they met the functional requirements in their demonstrations. This method of evaluating information systems provides an incremental advantage over use of requirements or scenarios by themselves.
BACKGROUND: Increasing numbers of Americans are receiving care within managed care organizations (MCOs), and the ability of MCOs to provide high-quality end-of-life care is under greater scrutiny. Although many anecdotal reports have been published, almost no research has been published on patient/family experiences with end-of-life care in MCOs. METHODS: We undertook a qualitative study of end-of-life care during 1996 and 1997 in the closed-panel staff-model, not-for-profit, health center division of Harvard Pilgrim Health Care. We collected and analyzed data from five focus groups composed of family members of patients who had died during the preceding year (n = 22) and four focus groups composed of clinicians and administrators who routinely care for dying patients and/or have responsibility for managing end-of-life care resources and systems (n = 31). RESULTS: Problems noted in this setting that are also reported in other health care settings included divergent expectations and unclear primary care/specialist roles and hospice/primary physician roles, difficulties in transitions across care settings, ineffective communication between physicians and patients/families about end-of-life care preferences, and lack of systematic attention to bereavement care. More unique to managed care settings were problems related to the absence of a consistently applied hospice benefit and concerns about the impact of cost containment on the quality of care, reflecting the conflict between the dual roles of MCOs as both insurers and providers of care. CONCLUSIONS: Our findings highlight specific issues involved in providing quality end-of-life care in MCOs and suggest areas for further exploration.
OBJECTIVE: To examine the relationship between adherence to antidepressant medications and HbA1c levels among patients with diabetes in a managed care setting. METHOD: The analysis included measures of HbA1c levels before, during, and after initial antidepressant use among 568 patients with diabetes enrolled in the Harvard Pilgrim Health Care insurance plan from 1991-1995. Adherence was defined as four refills in a six-month period after the first antidepressant prescription. General linear models using SAS PROC MIXED were used to estimate the effects of covariates including antidepressant adherence on HbA1c levels over time, comparing patients who were adherent to antidepressant medications to those patients who were non-adherent to antidepressant medications. RESULTS: Adherence to antidepressant treatment was not significantly associated with HbA1c levels among diabetic patients who are antidepressant users. Younger age, use of insulin and oral medications, and female gender were all significantly associated with HbA1c levels over time. CONCLUSIONS: Although we did not observe any association between level of adherence to antidepressant therapy among diabetic patients and levels of glucose control, our results confirm previously established associations between patient characteristics and glycemic control. Further research is needed to disentangle the complex relationship among antidepressant treatment adherence and diabetes outcomes.