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PubMed1998

Treatment of major depression before and after implementation of a behavioral health carve-out plan.

OBJECTIVE: The study examined utilization, payments, and quality indicators for treatment of major depressive disorder before and after the 1993 implementation of a behavioral health care carve-out plan for Massachusetts state employees who received medical coverage through indemnity plans or preferred provider organizations. METHODS: The sample of 2,259 enrollees with claims for treatment of major depressive disorder was drawn from the group of 39,541 persons continuously enrolled in preferred provider organizations or indemnity plans for fiscal years 1992 to 1995. A subsample of 243 users of inpatient services accounted for 352 admissions. Bivariate tests were used to compare utilization and quality indicators before and after implementation of the carve-out plan. Simple comparisons of current-year dollars were used. RESULTS: The proportion of enrollees with claims for treatment of major depressive disorder increased significantly under the carve-out plan. Inpatient utilization decreased substantially, mostly due to a significantly lower average length of stay (16 days before implementation of the carve-out plan and nine days after). Net inpatient payments fell 71 percent overall, 65 percent per admission, and 40 percent per day. The unadjusted proportion of discharged patients treated for major depressive disorder who were readmitted within 15 and 30 days did not change significantly. The unadjusted proportion of cases receiving follow-up within those time frames increased significantly. CONCLUSIONS: Implementation of a behavioral health carve-out plan may be accompanied by substantial reductions in inpatient utilization and payments for treatment of major depressive disorder. Descriptive findings suggest that such reductions may not have a detrimental impact on readmission and follow-up treatment rates within 30 days. However, this analysis did not control for patient characteristics, used short follow-up periods, and did not include some relevant outcome measures.

Behavior Therapy↗

PubMed1999

Diabetes preventive-care practices in managed-care organizations--Rhode Island, 1995-1996.

Diabetes mellitus affects 8% of the U.S. adult population and can lead to debilitating complications, including blindness, renal failure, cardiovascular disease, mobility impairment, and lower extremity amputation. Preventive care such as glycemic control and regular foot and eye examinations are recommended because of their efficacy in reducing diabetes-related complications. In the United States, managed care is an important provider of medical services for persons with diabetes. Persons with diabetes receiving care from a major health-maintenance organization (HMO) or a major preferred provider organization (PPO) in Rhode Island were surveyed in 1995 and 1996 to assess the level of care for three recommended preventive-care practices for diabetes: an annual dilated eye examination, semi-annual foot examination, and annual glycosylated hemoglobin (GHb) assessment. This report summarizes the findings from this survey, which indicated that 87% of persons with diabetes received eye examinations and approximately 55% received semi-annual foot examinations and annual GHb assessments.

Adult↗

PubMed1994

The transformation of PPOs under health care reform: strategies for survival.

Preferred provider organizations have effectively blended the supply-side utilization control strategy and the demand-side cost-sharing strategy and have become the most prevalent form of managed care in the United States. Preferred provider organizations have successfully controlled health care costs for many employers; nonetheless, the very existence of many PPOs is threatened by the Clinton Administration's health care reform proposal. This article examines alternative strategies that might be employed by PPOs to survive the challenges posed by health care reform.

Forecasting↗

PubMed2000

Providing managed care options for a large population: evaluating the CHAMPUS reform initiative. Civilian Health and Medical Program of the Uniformed Services.

OBJECTIVES: To evaluate a managed care demonstration project in CHAMPUS (Civilian Health and Medical Program of the Uniformed Services), the insurance program covering physical and mental health care services for the dependents of active duty military personnel, military retirees, and the retirees' dependents. The demonstration project added a health maintenance organization (HMO) option and a preferred provider organization (PPO) option to the standard CHAMPUS coverage and allowed beneficiaries to select the coverage option they preferred. DATA SOURCES: Utilization, costs, access, and beneficiary satisfaction were measured using data from CHAMPUS claims records, the Defense Enrollment Eligibility Reporting System, the demonstration project contractor's HMO enrollment file, the contractor's list of network hospitals, and two surveys of CHAMPUS beneficiaries. STUDY DESIGN: Changes in utilization at 11 demonstration sites were compared with changes in utilization at 11 matched control sites. The effect of the demonstration project on costs was evaluated by estimating the costs for the demonstration sites both with and without the managed care options based on data from the control sites. Access to care and satisfaction were compared between the demonstration sites and control sites based on beneficiary surveys. DATA COLLECTION: All claims in both demonstration and control sites were used in estimating utilization changes. Two mailed surveys were sent to a randomly selected sample of active duty and retiree households with CHAMPUS beneficiaries; the sample was stratified by beneficiary type (active duty or retiree) and site. PRINCIPLE FINDINGS: Overall utilization in the CHAMPUS system decreased at the demonstration sites but stayed approximately the same at the control sites. Utilization among the enrollees in the HMO demonstration option, however, increased dramatically. Patient access to care and satisfaction generally remained at the same levels at both demonstration and control sites, but enrollees in the HMO option reported higher satisfaction. Costs to the government at the demonstration areas, based on regression estimates from the control sites, were about the same or slightly higher than what they would have been under the standard CHAMPUS system. CONCLUSIONS: Managed care plans for large government-sponsored insurance programs can reduce utilization and maintain patient access and satisfaction. Careful structuring of such plans is needed, however, if they are to reduce costs.

Health Benefit Plans, Employee↗

PubMed2004

Employee choice of consumer-driven health insurance in a multiplan, multiproduct setting.

OBJECTIVE: To determine who chooses a Consumer-Driven Health Plan (CDHP) in a multiplan, multiproduct setting, and, specifically, whether the CDHP attracts the sicker employees in a company's risk pool. STUDY DESIGN: We estimated a health plan choice equation for employees of the University of Minnesota, who had a choice in 2002 of a CDHP and three other health plans--a traditional health maintenance organization (HMO), a preferred provider organization (PPO), and a tiered network product based on care systems. Data from an employee survey were matched to information from the university's payroll system. PRINCIPAL FINDINGS: Chronic illness of the employee or family members had no effect on choice of the CDHP, but such employees tended to choose the PPO. The employee's age was not related to CDHP choice. Higher-income employees chose the CDHP, as well as those who preferred health plans with a national provider panel that includes their physician in the panel. Employees tended to choose plans with lower out-of-pocket premiums, and surprisingly, employees with a chronic health condition themselves or in their family were more price-sensitive. CONCLUSIONS: This study provides the first evidence on who chooses a CDHP in a multiplan, multiproduct setting. The CDHP was not chosen disproportionately by the young and healthy, but it did attract the wealthy and those who found the availability of providers more appealing. Low out-of-pocket premiums are important features of health plans and in this setting, low premiums appeal to those who are less healthy.

Choice Behavior↗

PubMed2005

The Federal Employees Health Benefits Program: a model for competition in rural America?

CONTEXT: The Medicare Prescription Drug, Improvement, and Modernization Act of 2003 (MMA) created the Medicare Advantage (MA) program, which promotes the entry of private Preferred Provider Organization (PPO) plans into regions that have not previously had Medicare managed care plans. The assumption that a competitive environment will develop is based on experiences in the Federal Employees Health Benefits Program (FEHBP). PURPOSE: The authors test the hypothesis that the FEHBP has fostered an environment of competing health plans, especially preferred provider organizations (PPOs), in rural areas. METHODS: Data from the US Office of Personnel Management are used to quantify the number of FEHBP-certified plans in each US county and the number of enrollees in each plan. Data from the Area Resource File are used to measure independent variables in multivariate analysis to account for the number of FEHBP-certified health plans competing in each US county. FINDINGS: While 98% of all counties have at least 3 plans with enrollment, in many sparsely populated rural areas, only 1 of the plans is an open-enrollment plan (excludes plans for letter carriers). There is a strong relationship between the number of FEHBP plans and areas with high population counts and high population density. In many counties with low population counts (under 3,000), most PPOs are not contracting with the nearest primary care provider. CONCLUSIONS: The FEHBP is not a perfect predictor of MA plan activity because the MA program does not use the FEHBP approach of certifying regional plans that must offer local access. However, the FEHBP experience indicates that plans are attracted to areas with high population counts and high population density.

Economic Competition↗

PubMed1992

The effects of preferred provider options in fee-for-service plans on use of outpatient mental health services by three employee groups.

Descriptions of how preferred provider organizations (PPOs), offered as options to employees enrolled in fee-for-service plans, affected use of outpatient mental health services are provided. Data are from the RAND Preferred Provider Organization Study, which has a sample of employees who enrolled in fee-for-service plans 1 year before and 2 years after a PPO option was offered by three employers in two U.S. sites. To study effects of the optional PPOs on access to mental health care, usage patterns among those who initially stated that they did or did not intend to use PPO providers were examined. By the end of the second post-PPO year, employees had a similar annual probability of having an outpatient mental health visit whether or not they initially intended to use PPO providers. However, during the first post-PPO year, there was a decrease in the probability of use for those initially intending to use PPO providers, relative to those who did not intend to do so, among employees who had no regular medical provider. To study effects of the PPO option on usage levels of mental health care services, users of mental health services who primarily visited PPO were compared with those who primarily visited non-PPO providers. Users who visited PPO providers had significantly lower levels of use, controlling for other factors, than those who primarily visited non-PPO providers. Therefore, despite lower cost sharing for services received from PPO providers, the PPO option appeared to lower outpatient mental health care costs while having no more than a transient effect on access. This study did not evaluate mental health outcomes.

Adult↗

PubMed2000

A need for managed care in Saudi Arabia.

Is the Kingdom of Saudi Arabia getting value for money invested in health? Quality care is being provided throughout health facilities in the Kingdom, however there is minimal control of utilization in all health sectors, consequently leading to abuse and over utilization, particularly in the public sector. Managed care programs have proven effective in reducing unnecessary inpatient and ancillary service utilization by reducing use of expensive procedures and unnecessary, highly specialized services, and shifting to less expensive care options. Health maintenance organizations are the best example of a managed health care model; tracking good performance and cost savings averaging between 20-40% compared to more traditional health plans. Key features of health maintenance organizations include serving a defined population voluntarily enrolled in the health plan; assumption of contractual responsibility and financial risk by plan to provide a range of services, and payment of a fixed periodic payment by the enrollee, independent of the actual use of services. The key characteristic that distinguishes health maintenance organizations from other delivery systems is prepayment for the care that is provided. Preferred Provider Organizations offer discounts for services received from a selected set of physicians and hospitals. Services received by enrollees are not fully reimbursed from this selected list of providers. Preferred Provider Organizations use health maintenance organizations administrative processes for controlling costs but do not include some of the intrinsic cost and quality controls of health maintenance organizations. Review of several studies indicate that patients enrolled in prepaid group practices (managed care organizations) were hospitalized 15-40% less often than those enrolled in fee-for-service health plans.

Cost-Benefit Analysis↗

PubMedDate not supplied

Public sector employer evaluation of health plans in the United States.

Recently, public employers have experimented with different types of health plans including Indemnity, Health Maintenance Organization (HMO) and Preferred Provider Organization (PPO) plans. This study examines factors that are related to municipal employer satisfaction with each type of plan. The data are drawn from the International City/County Management Association (ICMA) of municipal healthcare practices in 3301 US cities. Many more cities than anticipated used only indemnity plans, although there was widespread experimentation with managed care plans. Jurisdictions that offered only one type of plan showed highest satisfaction levels with HMOs, followed by PPOs and indemnity plans. In jurisdictions that offered multiple plans, patterns of satisfaction varied with the types of plans involved. Three factors were found to be correlated with employer plan satisfaction. As employee complaints and cost to the jurisdiction increased, plan satisfaction decreased. As the number of services offered by a plan increased, plan satisfaction also increased. While most municipalities contracted for health plans as individual employers, a small proportion contracted as part of a consortium: there was no statistically significant difference in satisfaction levels between the two arrangements.

Consumer Behavior↗

PubMed2003

Effects of physician-related factors on adult asthma care, health status, and quality of life.

PURPOSE: To study the association of physician characteristics, the characteristics of their practice settings, patient mix, and reported frequency of prescribing asthma medication with patients' health status and health-related quality of life in asthma. METHODS: We conducted a mail-back survey of physicians (n = 147) that included demographic characteristics, practice and training characteristics, and reported prescribing frequencies for common asthma treatments. We also conducted structured telephone interviews with 317 of their patients, assessing demographic characteristics, health status (as measured by the Short Form-12 [SF-12] physical component score), and asthma-specific quality of life (as measured by the Marks questionnaire). RESULTS: In adjusted analyses, pulmonary specialists were more likely to report using leukotriene modifiers (odds ratio [OR] = 4.7; 95% confidence interval [CI]: 1.2 to 18) and theophylline (OR = 3.0; 95% CI: 1.0 to 9.0) in adult patients with asthma. Working in a practice of >75% health maintenance organization (HMO)- or preferred provider organization (PPO)-insured patients was associated with a lower likelihood of prescribing leukotriene modifiers (OR = 0.1; 95% CI: 0.01 to 0.5). Adjusting for patient demographic characteristics and steroid dependence, physician prescribing tendencies were not associated with patients' perceived health status or quality of life. Although an HMO- or PPO-predominant practice was associated with better physical health status (mean difference in SF-12 physical component score, 3.1; 95% CI: 0.05 to 6.2; P = 0.05), there was no statistical association with quality of life. CONCLUSION: The characteristics of physicians, their practices, and the asthma medication prescribing strategies that they adopt are not strongly associated with patients' perceived outcomes.

Adult↗

PubMedDate not supplied

Insurance status and delay in orthotic treatment in children.

OBJECTIVE: To determine if the type of health insurance is associated with a delay in children obtaining orthoses. METHODS: The medical records of 60 children who were prescribed an ankle-foot orthosis (AFO) or thoracolumbosacral orthosis (TLSO) were retrospectively reviewed. Ten children were randomly chosen with either of 3 types of insurance (government, health maintenance organizations [HMOs], and preferred provider organizations [PPOs]) with an orthosis provided by a single supplier. The time interval between prescription and insurance company authorization was recorded, as well as the interval between prescription and procurement of the orthosis. RESULTS: There were significant differences in the time from prescription to authorization of orthoses between insurance types (P = 0.001) and time from authorization until brace procurement between insurance types (P = 0.01). Children with PPO insurance received authorization for an AFO faster than children with government insurance or an HMO (P < 0.05). Children with government insurance received authorization for a TLSO significantly later than children with PPO insurance (P = 0.004) or HMO insurance (P = 0.03). The difference in time between authorization and procurement of a TLSO in children with PPO insurance (36 days) was strikingly different from that of children with government insurance (123 days) (P = 0.003). DISCUSSION: This study documents that children with government insurance face delays in obtaining orthotic treatment compared with children with PPO insurance. The delay in the procurement of the more expensive brace (TLSO is approximately 4 times the cost of an AFO) correlated to more striking delays in the government-insured population.

Child↗

PubMed2004

Risk segmentation related to the offering of a consumer-directed health plan: a case study of Humana Inc.

OBJECTIVE: To determine whether the offering of a consumer-directed health plan (CDHP) is likely to cause risk segmentation in an employer group. STUDY SETTING AND DATA SOURCE: The study population comprises the approximately 10,000 people (employees and dependents) enrolled as members of the employee health benefit program of Humana Inc. at its headquarters in Louisville, Kentucky, during the benefit years starting July 1, 2000, and July 1, 2001. This analysis is based on primary collection of claims, enrollment, and employment data for those employees and dependents. STUDY DESIGN: This is a case study of the experience of a single employer in offering two consumer-directed health plan options ("Coverage First 1" and "Coverage First 2") to its employees. We assessed the risk profile of those choosing the Coverage First plans and those remaining in more traditional health maintenance organization (HMO) and preferred provider organization (PPO) coverage. Risk was measured using prior claims (in dollars per member per month), prior utilization (admissions/1,000; average length of stay; prescriptions/1,000; physician office visit services/1,000), a pharmacy-based risk assessment tool (developed by Ingenix), and demographics. DATA COLLECTION/EXTRACTION METHODS: Complete claims and administrative data were provided by Humana Inc. for the two-year study period. Unique identifiers enabled us to track subscribers' individual enrollment and utilization over this period. PRINCIPAL FINDINGS: Based on demographic data alone, there did not appear to be a difference in the risk profiles of those choosing versus not choosing Coverage First. However, based on prior claims and prior use data, it appeared that those who chose Coverage First were healthier than those electing to remain in more traditional coverage. For each of five services, prior-year usage by people who subsequently enrolled in Coverage First 1 (CF1) was below 60 percent of the average for the whole group. Hospital and maternity admissions per thousand were less than 30 percent of the overall average; length of stay per hospital admission, physician office services per thousand, and prescriptions per thousand were all between 50 and 60 percent of the overall average. Coverage First 2 (CF2) subscribers' prior use of services was somewhat higher than CF1 subscribers', but it was still below average in every category. As with prior use, prior claims data indicated that Coverage First subscribers were healthier than average, with prior total claims less than 50 percent of average. CONCLUSIONS: In this case, the offering of high-deductible or consumer-directed health plan options alongside more traditional options caused risk segmentation within an employer group. The extent to which these findings are applicable to other cases will depend on many factors, including the employer premium contribution policies and employees' perception of the value of the various plan options. Further research is needed to determine whether risk segmentation will worsen in future years for this employer and if so, whether it will cause premiums for more traditional health plans to increase.

Adult↗

PubMed2004

The effect of area HMO market share on cancer screening.

OBJECTIVE: Managed care may have widespread impacts on health care delivery for all patients in the areas where they operate. We examine the relationship between area managed care activity and screening for breast, cervical, and prostate cancer among patients enrolled in more managed care plans and patients who are enrolled in less managed plans. DATA AND METHODS: Data on cancer screening from the 1996 Medical Expenditure Panel Survey (MEPS) were linked to data on health maintenance organization (HMO) and preferred provider organization (PPO) market share and HMO competition at the metropolitan statistical area (MSA) level. Logistic regression analysis was used to examine the relationship between area managed care prevalence and the use of mammography, clinical breast examination, Pap smear, and prostate cancer screening in the past two years, controlling for important covariates. RESULTS: Among all patients, increases in area-level HMO market share are associated with increases in the appropriate use of mammography, clinical breast exam, and Pap smear (OR for high relative to low managed care areas are 1.75, p < .01, for mammography, 1.58, p < .05, for clinical breast exam, and 1.71, p < .01, for Pap smear). In analyses of subgroups, the relationship is significant only for individuals who are enrolled in the nonmanaged plans; there is no relationship for individuals in more managed plans. No relationship is observed between area HMO market share and prostate cancer screening in any analysis. Neither the level of competition between area HMOs nor area PPO market share is associated with screening rates. CONCLUSIONS: Area-level managed care activity can influence preventive care treatment patterns.

Adolescent↗

PubMed2004

Analysis of costs, length of stay, and utilization of emergency department services by frequent users: implications for health policy.

UNLABELLED: In efforts to decrease emergency department (ED) crowding and health care costs, frequent users of ED services have been targeted for interventions to decrease their utilization. Previous studies have had different definitions for "frequent users" and have considered all frequent users as a homogeneous group. To the authors' knowledge, no study has examined visit characteristics and resource utilization of different levels of frequent use. OBJECTIVES: 1) to determine the rates of ED utilization by five user groups defined by number of annual visits, 2) to examine variations in visit characteristics by frequency of ED use, and 3) to compare levels of resource utilization among frequent user groups. METHODS: This was a retrospective, cross-sectional study of clinical and financial records for all ED visits to an urban, academic hospital in 2001. Multinomial logistic and linear regression models were used for analyses. Estimates were corrected for multiple comparisons (with Bonferroni corrections), where applicable, and adjusted for clustering within individuals (with Huber-White estimators). Outcome measures were triage acuity, diagnosis-related group (DRG) severity, disposition status, primary complaint, medical diagnosis, hospital inpatient length of stay, payment method, costs, and demographics. RESULTS: Patients with three to 20 visits were more likely to be admitted to the hospital than patients visiting once or twice. Patients visiting more than 20 times were less likely to require hospital admission and more likely to present with "nonurgent" conditions, have lower severity scores, and elope or leave the ED without medical attention than patients visiting the ED once. The group had fewer inpatient days and lower average costs than patients visiting once. Patients with six to 20 visits had traditional Medicaid coverage more often than those with one or two visits. Virtually no patients visiting more than 20 times had Medicare or Medicaid managed care, a health maintenance organization, or a preferred provider organization. CONCLUSIONS: Frequent ED users are a heterogeneous group. Many patients previously thought to overutilize the ED for socioeconomic or insignificant medical problems are as sick as less-frequent ED users. There is a small subgroup with more than 20 visits who are less ill or injured but also incurred lower-than-average costs per visit.

Adult↗

PubMed1986

Social medicine vs professional dominance: the German experience.

This article describes the efforts by German workers' groups and pioneering social physicians to design health care services oriented to prevention and cost-effective treatment. Jews played a key role in developing these prototypes of today's health maintenance organizations (HMOs) and preferred provider organizations (PPOs). The growing success of these services threatened private practitioners in a number of ways. They formed a trade union and took militant action. Stage by stage, the profession asserted its dominance, culminating in an alliance with the National Socialists and Hitler to take over these services and to purge them of socialist and Jewish physicians. Medical societies assisted Hitler in his policies of "purification," and the health care delivery systems shifted from being local, patient-centered, and health-oriented to being national, physician-centered, and focused on curing illness. After World War II, these changes were not reversed as part of denazification, and 40 years later, social medicine has yet to recover.

Germany↗

PubMed1993

VIP interview: Paul M. Ellwood, Jr., M.D.

Paul Ellwood, Jr., M.D., is president of Health Outcomes Institute, a nonprofit health policy research organization, and President of the Jackson Hole Group in Teton Village, Wyoming, a health care reform policy think tank. He has been called one of the most important figures in American health care in the last half century. Dr. Ellwood has been a leader in introducing competition into the marketplace through health maintenance organizations (HMOs) and preferred provider organizations (PPOs); encouraging the business coalition movement; developing medical staff-hospital joint venture approaches to integrating health delivery, and installing the Outcomes Management System for payors, patients, and providers. He is now concentrating on working with health care leaders of the Jackson Hole Group to devise and implement The 21st Century American Health System, a comprehensive proposal for health care policy reform in the private and public sectors. Their objective is to ensure universal insurance coverage, managed competition, and health outcomes accountability.

Managed Care Programs↗

PubMed1991

Joint-venture, capitation model can strengthen market share.

As health maintenance organizations (HMOs) and preferred provider organizations (PPOs) control an increasingly larger percentage of the healthcare market, many hospitals are entering capitation contracts to capture and preserve market share. A joint-venture and capitation model may provide an additional mechanism for large referral centers and community hospitals to jointly maintain or increase market share through improved service delivery. While the model includes many benefits, hospitals should thoroughly consider ramifications. Only through substantial institutional commitment, careful planning, and ongoing management will the model prove successful.

Capitation Fee↗

PubMed1997

Health insurance coverage at midlife: characteristics, costs, and dynamics.

Recent data from the first two waves of the Health and Retirement Study are analyzed to evaluate prevalence of different types of health insurance, characteristics of different plan types, and change sin coverage as individuals approach retirement age. Although overall rates of coverage are quite high among the middle-aged, the risk of noncoverage is high within many disadvantaged groups, including Hispanics, low-wage earners, and the recently disabled. Sixty percent of individuals with health benefits are enrolled in health maintenance organizations (HMOs) or preferred provider organizations (PPOs). In addition, one-fourth of enrollees in fee-for-service (FFS) plans report restrictions in their access to specialists.

Age Factors↗