SEARCH · PubMed Health

Results for “Management”

Explore indexed PubMed citations for clinical trials, systematic reviews and public health research. Read source abstracts and follow each citation to its original PubMed record.

Quote a phrase for an exact phrase match. Source license links do not imply unrestricted reuse.

At least 181 records · Page 10Linked to original sources

PubMedDate not supplied

Redesigning case management in managed care: an eclectic approach: from city to ranch.

Case management programs are a common approach to managing the quality and cost of services in managed care organizations. Once developed these programs may grow stagnate as the managed care member population grows and changes. This article presents a redesign project initiated by a managed care organization located in a rural Southwest region of the United States. Nursing theory and case management standards of practice form the basis of the redesign project and will be discussed. The case management model, including roles and responsibilities of staff, are presented. Results and future implications are identified.

Case Management↗

PubMed2003

A prospective one-year outcome study of interdisciplinary chronic pain management: compromising its efficacy by managed care policies.

UNLABELLED: Although interdisciplinary pain management programs are both therapeutically effective as well as cost-effective, they are currently being underutilized because of managed care policies. We used this prospective comparison trial, with 1-yr follow-up of chronic pain patients, to demonstrate the short- and long-term efficacy of an interdisciplinary pain management program, and evaluate the impact of managed care's physical therapy "carve out" practices on these treatment outcomes. Consecutive chronic pain patients (n = 201) were evaluated, some of whom had their physical therapy "carved out" from this integrated program. Results revealed that successful completion of interdisciplinary pain management was therapeutically effective. Most importantly, physical therapy "carved out" practices had a negative impact on both the short-term and 1-yr follow-up outcome measures. Thus, interdisciplinary pain management is effective in treating the major health problem of chronic pain. However, insurance carrier policies of contracting treatment "carve outs" significantly compromise the efficacy of this evidence-based, best standard of medical care treatment. This raises important medico-legal and ethical issues. IMPLICATIONS: Interdisciplinary pain management is effective and cost-effective in treating the major health problem of chronic pain. The present study demonstrated its efficacy using a prospective, 1-yr posttreatment evaluation methodology. Moreover, physical therapy "carve out" practices by insurance carriers had a negative impact on the outcomes, raising important medico-legal and ethical issues.

Chronic Disease↗

PubMedDate not supplied

Integrating disease management into the outpatient delivery system during and after managed care.

Managed care introduced disease management as a replacement strategy to utilization management. The focus changed from influencing treatment decisions to supporting self-care and compliance. Disease management rendered operational many elements of the chronic care model, but it did so outside the delivery system, thus escaping the financial limitations, cultural barriers, and inertia inherent in effecting radical change from within. Medical management "after managed care" should include the functional and structural integration of disease management with primary care clinics. Such integration would supply the infrastructure that primary care physicians need to coordinate the care of chronically ill patients more effectively.

Ambulatory Care↗

PubMedDate not supplied

Managing the managed care market competition.

Market competition among rival managed care plans has been rapidly changing the health care delivery of individual provider organizations, Local health care markets, and the American health care system. Yet, there are critical unanswered questions about managed care, and there are economic and structural problems inherent in health care markets. Thus, managed care market competition alone might not be sufficient to solve some important problems and meet the important goals of our health care system and society. Market competition, combined with some regulation to managed the competition, is more likely to achieve those goals. Market competition among managed care plans is described, and problems of this type of competition are explained in this article. One approach to managing the managed care market competition, which blends market competition with government regulation, is also presented.

Capitation Fee↗

PubMedDate not supplied

New path for health-care leadership: clinical systems management. CLMA Clinical Systems Management Task Force.

This article sets forth a concept and an action plan to support the educational needs for the clinical systems manager. This article describes the roles, competencies, and tasks of the clinical systems manager and defines specific intermediate and long-term steps. Clinical systems management is umbrella terminology used to describe an array of related jobs including, but not necessarily limited to, multidepartmental or interdisciplinary management, regional or health system-wide laboratory management, and traditional laboratory management. In general, clinical systems management recognizes the emergence of new jobs, with the primary responsibility of leading the integration of clinical services within health-care systems.

Data Collection↗

PubMed2002

Integrated, automated revenue management for managed care contracts.

Faced with increasing managed care penetration and declining net revenue in recent years, healthcare providers increasingly are emphasizing revenue management. To streamline processes and reduce costs in this area, many healthcare providers have implemented or are considering automated contract management systems. When selecting such a system, healthcare financial managers should make certain that the system can interface with both patient-accounting and decision-support systems of the organization. This integration enhances a healthcare provider's financial viability by providing integrated revenue-management capabilities to analyze projected performance of proposed managed care contracts and actual performance of existing contracts.

Accounts Payable and Receivable↗

PubMed2003

Clinical management where medicine meets management. The American way.

Close relationships between business managers and clinicians, and purchaser and provider, are valuable in chronic-disease management. Organisations used high-quality clinical information and performance management. Chronic-disease management based on risk-management, proactive case managers and patient education is effective.

Case Management↗

PubMed1999

A managed care curriculum: developing a managed care curriculum for primary care residents.

INTRODUCTION: Managed care in its numerous forms is continuing to change the face of the healthcare system in the United States. IMPACT OF MANAGED CARE ON MEDICAL EDUCATION: As managed care continues to invade the market, it has a substantial influence in shaping the parameters of graduate medical education. Various surveys have shown that residents are under-trained in managed care principles and practice. There is a clear need for a residency curriculum that fully prepares students to keep pace with modern markets. EDUCATIONAL METHODOLOGY: This manuscript describes a curriculum which emphasizes the role of the primary care physician, cost-effective practice, multidisciplinary practice and evidenced-based strategies. Educational methods and concepts presented here are based on the recommendations of healthcare educators, extensive literature searches and United States advisory panels. After the curriculum is completed, the resident will: 1. Practice cost-effectively under 100% capitation and learn proper risk management. 2. Utilize epidemiological thinking and community-oriented primary care. 3. Function as a part of healthcare team and understand how to achieve cost-effective care for patients. 4. Practice the principles of continuous quality improvement and assess patient satisfaction. 5. Practice and adopt evidence-based medicine and guidelines. 6. Become skilled with computers including facility with literature searches, databases and the internet. 7. Practice a full spectrum of primary care emphasizing patient education and psychosocial health. 8. Understand the ethical issues pertinent to managed care practices. EVALUATION: The residency curriculum committee will evaluate the managed care curricular elements on an on-going basis. CONCLUSION: This comprehensive curriculum for primary care residents can help ensure success in the new healthcare marketplace.

Curriculum↗

PubMed2000

Educating residents about managed care: a partnership between an academic medical center and a managed care organization.

Physicians are taught to think in terms of individual patients rather than in terms of the health of a population, a view typically reinforced by residency training. Managers of managed care organizations estimate that it takes between one and two years of additional post-residency experience to prepare graduates of U.S. residency programs to practice in managed care settings. The authors describe a two-week block rotation in managed care and health system change that is required of all third-year medical residents at New York-Presbyterian Hospital/ Weill Cornell Medical Center. The program was developed through a partnership between the Joan and Sanford I. Weill Medical College of Cornell University, the New York-Presbyterian Hospital, and Empire BlueCross BlueShield. The authors discuss the rationale, curriculum content, teaching methods, and evaluation of the program, which is designed not only to educate residents about managed care but also to enable them to think critically about the changing health care system. The results of the program have exceeded expectations. Residents' knowledge of health economics, managed care concepts, and health system change, as measured by pre- and post-rotation tests, has shown a steep learning curve. Further, the residents have consistently given the rotation the highest ratings, and some residents have changed their career plans as a result of their participation. The program, which continues to expand, has demonstrated the potential of collaboration between traditional adversaries, an academic medical center and a managed care insurance company, and provides a replicable model for similar partnerships.

Academic Medical Centers↗

PubMed2000

Risk management in practice: how are we managing?

Aims to identify awareness of and involvement in risk assessments, training, incident reporting, information giving and consenting in an acute health care context. Explores how nurse managers perceived risk management as a concept and if they saw advanced neonatal nurse practitioners having a role to play in this activity. The method used was a postal survey of 62 nurse managers or clinical specialists responsible for neonatal nursing care services within NHS Trusts in the UK. Results show that while the nurse managers studies understood the definition of risk management in general, they were more vague about certain aspects of that definition. The nurse managers appeared to be passive in their dissemination and taking forward of risk management strategies, rather than proactively "promoting and helping them forward" as may be expected in facilitative managerial behaviour. Concludes that the challenges of clinical governance demand more proactive approaches to effect and demonstrate change, and support ongoing clinical quality improvements.

Attitude of Health Personnel↗

PubMed1999

Strategies in disability management. Corporate disability management programs implemented at the work site.

Managers are challenged to demonstrate all programs as economically essential to the business, generating an appreciable return on investment. Further challenge exists to blend and integrate clinical and business objectives in program development. Disability management programs must be viewed as economically essential to the financial success of the business to assure management support for clinical interventions and return-to-work strategies essential for a successful program. This paper discusses a disability management program integrating clinical and business goals and objectives in return-to-work strategies to effect positive clinical, social-cultural, and business results. Clinical, educational, social, and economic challenges in the development, implementation, and continued management of a disability program at a large corporation with multiple global work sites are defined. Continued discussion addresses the effective clinical interventions and educational strategies utilized successfully within the workplace environment in response to each defined challenge. A multiple disciplinary team approach, clinical and business outcome measures, and quality assurance indicators are discussed as major program components. This article discusses a successful program approach focusing on business process and methodology. These parameters are used to link resources to strategy, developing a product for implementing and managing a program demonstrating economic value added through effective clinical medical case management.

Accidents, Occupational↗

PubMed2000

Utilization management in a large managed behavioral health organization.

OBJECTIVE: The utilization management process of a managed behavioral health organization was examined to determine the frequency and types of reviews and the extent to which rationing of service was achieved through the denial of services. METHODS: A case study of the utilization management program of a large managed behavioral health organization was done. Information was gathered from claims for 1997, and utilization review data were drawn from 51 plans. Data were examined by review type and authorization actions. RESULTS: The utilization management program performed a total of 9, 639 reviews. The most common type was concurrent review for additional outpatient therapy visits (46 percent). The second most common type was concurrent facility review (12.9 percent). The vast majority of authorizations were approved at the level requested by the provider (91.8 percent). Very few services were denied (.8 percent) or approved at a level lower than requested by the provider (1.3 percent). CONCLUSIONS: Although concerns have been raised about the high denial rates of utilization management programs, this study found very low denial rates. Further studies are needed to determine the precise mechanisms used in utilization management programs to control utilization. In addition, the large number of reviews raises questions about the time and opportunity costs of the review process.

Behavior Therapy↗

PubMedDate not supplied

Improving outpatient diabetes management through a collaboration of six competing, capitated Medicare managed care plans.

This report addresses diabetes care in the managed care setting and improvement in care brought about by collaboration between 6 Medicare managed care plans (MCPs) and a Peer Review Organization (PRO). The objective was to improve the quality of care of outpatient diabetes patients provided by primary care physicians through the mutual collaboration of 6 Medicare managed care plans and a Medicare Peer Review Organization. The design involved pre-post intervention trial based on 2 random samples, a baseline sample drawn in 1995 and a remeasurement sample drawn in 1996. Medical records of patients in both samples were reviewed by the PRO to determine provision of 14 quality indicator services over a 1-year period. The setting was 6 Arizona Medicare managed care plans comprising approximately 40% of the Arizona Medicare population. Two random samples were drawn from type 2 diabetes patients continuously enrolled in the same managed care plan for at least 1 year. The intervention was comparative feedback of baseline data by the PRO, enabling each plan to compare itself to any other plan on any or all indicators. Each plan developed and implemented its own intervention in response to the 1995 baseline results. The main outcome measures were mean HbA1c, the proportion of HbA1c values below 8%, and positive change in provision of 14 quality indicator services. At postintervention remeasurement, mean HbA1c values fell from 8.9 +/- 2.2 to 7.9% +/- 2.1, and the proportion of patients with HbA1c values below 8.0% rose from 40% to 61.6%. The proportion of the 14 indicator services provided to patients rose from 35% to 55%. The mean number of physician office visits fell 13% and the number of services provided per visit doubled. We conclude that improving the process of care improves glycemic control. Better outpatient diabetes management in competing, capitated managed care plans is an attainable goal when mediated through a neutral third party such as a PRO.

Ambulatory Care↗

PubMed1996

The role of pharmacoeconomics in disease management. A pharmaceutical benefit management company perspective.

In the US, managed-care organisations (MCOs) have turned to pharmacy benefit management (PBM) companies to contain costs and provide total disease management packages. The demand for pharmacoeconomic research and information by purchasers of healthcare has contributed to the growth of PBM companies and to recent acquisitions by pharmaceutical manufacturers. PBMs influence prescribing via formulary management and drug utilisation review (DUR). Formularies are generally open, and pharmacoeconomic data contribute to formulary management decisions. Prospective and concurrent DURs used in hospitals can soon be integrated into community pharmacy, as PBMs obtain integrated online information about prescribing. PBM prescription databases are used as as educational tools for physicians, providing drug utilisation data, formulary compliance, generic prescribing rates, and guidelines for pharmacotherapy for particular conditions. They can also evaluate medication regimens for patients with particular problems such as drug-drug interactions. However, PBM databases typically lack patient diagnostic, outcome and medical claim data. PBMs will be better placed to move from medication management to disease management when they can obtain these data and link them appropriately to their own prescribing and physician databases.

Drug Utilization Review↗

PubMed1991

Beyond management by objectives: the implementation of a goal-directed performance management system in an Australian teaching hospital.

This paper describes management by objectives (MBO) as an approach by which organisations can be managed, with particular reference to health care institutions. An evaluation of MBO is presented and the disadvantages of MBO are discussed. A more comprehensive performance management system than MBO is advocated. The experience of St Vincent's Hospital, Sydney, in designing and implementing a goal-directed performance management program which builds on MBO methodology, is described. This experience provides guidelines by which senior managers may successfully implement goal-directed performance management programs in health care institutions in order to enhance organisational effectiveness and the goal-oriented behaviour of managers.

Employee Performance Appraisal↗

PubMed1992

Managed care and case management of substance abuse treatment.

Managed care has become an important subject for health service research and is used increasingly by health care payers to control health care use and costs. Health services research on managed care has relevance to the evaluation of case management of persons with substance abuse problems. Two issues in managed care that are particularly relevant to case management are the lack of explicit, widely accepted criteria for managed care and the lack of demonstrated cost savings attributable to managed care. Thorough, systematic evaluative research needs to be done before these issues are well understood.

Cost Savings↗

PubMed2003

A critical analysis of the broker and strengths models of case management: identifying a potential framework for community case managers.

In Canada, case management has been applied to a variety of health care settings including the community care system, where case managers have become an integral component in the delivery of government-funded, in-home services. Specifically in Ontario, home care is accessed through 43 Community Care Access Centres (CCACs), and the model currently driving case management practices most closely resembles the Broker model. Not only does this create moral distress among the case managers, but it also hinders their ability to meet the health care needs of the community as current cost containment strategies can lead to suffering and emotional distress for a significant portion of the people who are cut from care. This article will identify a potential framework for case managers in CCACs. The Strengths model offers a framework that is consistent with the goals of Ontario case managers and is committed to client autonomy, empowerment, and client-driven care. Given the multitude of health care challenges facing CCAC case managers today, the Strengths model of practice has the potential to contain and maintain costs without compromising the psychological wellbeing and health care needs of the community.

Caregivers↗

PubMed2006

The WPI's review of Wisconsin's managed care climate for pain management: opportunities for improvement.

BACKGROUND: Reimbursement obstacles, such as inadequate insurance coverage, have been identified as barriers to adequate pain management. The purpose of this study was to determine Wisconsin insurers' and managed care organizations' (MCOs) policies and practices regarding pain treatment and MCO medical directors' perceptions of barriers to providing effective pain management for their enrollees. METHODS: A descriptive qualitative design was used with semi-structured interviews of 6 administrative executives of commercial health management organizations' products from the major insurers in Wisconsin. RESULTS: None of the companies interviewed had systematically tracked data or had processes in place to allow them to track, analyze or trend data specific to pain management. Chronic noncancer pain is recognized more frequently as an insurance coverage issue because of high drug costs. Pharmacologic and interventional therapies are routinely covered compared with nonpharmacologic therapies with some prior authorizations, especially for newer medications. A uniformly identified barrier was lack of a comprehensive, interdisciplinary, integrated approach to pain management and inadequate data on the cost effectiveness of various approaches. CONCLUSIONS: Opportunities exist to educate and improve communication between health care professionals, purchasers of health care (employers), primary care providers and pain specialists. The economics of pain management needs to be made more "visible" through the development of coding and tracking mechanisms.

Data Collection↗