PubMed Health⌕ Search
Home/Archive/PubMed

PubMed · 9348998

Managing quality from the utilization management perspective: the provider view.

K S Miles
View original source ↗Export metadata ↓

Abstract

As a contracted provider for a popular health maintenance organization, you receive notice that it is converting its provider contracts to capitated reimbursement models. Reluctantly, you read to see how this change affects your practice. Are you positioned to accept "risk" for your patients? How will you manage your risk? Can you afford to terminate your relationship with this managed care organization and lose your patients to providers who are eager to expand their practice and patient base? This article presents an overview of capitation and ways to manage capitation while promoting quality care and outcomes for your patients.

Explore related subjects

Capitation FeeCase ManagementHealth PersonnelHumansManaged Care ProgramsPatient DischargeReferral and ConsultationTotal Quality ManagementUtilization ReviewJournal ArticleReview

Keep this discovery

Explore connections, maps & timelines

BibTeXRIS

K S Miles. 1997. Managing quality from the utilization management perspective: the provider view.. https://pubmed.ncbi.nlm.nih.gov/9348998/

Cite the original work for its findings. Save a collection to share your selection of sources.

KEEP EXPLORING

Related citations

PubMed2007

Caregivers' ratings of access: do children with special health care needs fare better under fee-for-service or partially capitated managed care?

OBJECTIVE: The objective of this study was to evaluate how enrollment in a partially capitated managed care (MC) option versus the fee-for-service (FFS) system affects caregivers' ratings of dimensions of access to services among children with special health care needs (SHCN). SUBJECTS: The data were collected from telephone interviews during the summer and fall of 2002 with a random sample of 1088 caregivers of children with SHCN who qualified for Supplemental Security Income and therefore were enrolled the Medicaid program for children with SHCN in the District of Columbia. RESEARCH DESIGN: We used a 2-step procedure in which we first estimated plan choice and then constructed a selectivity correction to control for the potential selection bias linked to plan choice. We estimated the second stage equations predicting caregiver's ratings of dimensions of access as a function of the selectivity correction, the plan choice dummy variable and other exogenous variables. RESULTS: After controlling for the potential selection bias linked to plan choice and other confounding factors, we find that caregivers of children in FFS are significantly more likely than caregivers of children enrolled in the partially capitated MC plan to rate the following dimensions of access as either fair or poor: "access to specialists' care" (P < 0.01), "access to emergency room care" (P < 0.01), "convenience of the doctor's office" (P < 0.01), and "waiting time between making the appointment actual visit" (P < 0.05). CONCLUSIONS: We attribute these differences in caregivers' ratings of dimensions of access that exist between partially capitated MC and FFS enrollees to case management and care coordination services along with higher fees paid for pediatrician's and specialists' services available under MC option.

Capitation Fee↗
PubMed2006

Coordinated care in a 'consumer-driven' health system.

High-deductible health plans--with and without spending accounts--are gaining ground. Will these evolving benefit designs complement or undermine the coordination of care for patients with chronic illnesses? Based on an October 2005 roundtable sponsored by the California HealthCare Foundation and Health Affairs, this paper discusses the implications of a changing health insurance market for the chronically ill, capitation payment for medical groups, and consumers navigating the system.

Capitation Fee↗