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PubMed1990

A managed care approach to outpatient review.

The recent growth in outpatient services has been the result of both increased use of new and improved technology, along with a shift to an ambulatory setting for many previously performed inpatient tests and procedures. Employers have seen an almost unchecked rapid growth in this portion of health care costs, with no signs of slowing down. This article attempts to show a basic step-by-step approach to identifying and reviewing some of the major cost generators through a managed care program.

Ambulatory Care↗
PubMed1991

Rollover effects in gatekeeper programs: cushioning the impact of restricted choice.

Public and private medical care plans that restrict the beneficiary's choice of providers have experienced rapid growth in the past decade as a means to contain costs and coordinate care. Such plans have been criticized for engendering beneficiary dissatisfaction and potentially impeding access to necessary care. Some of the objections to primary care "gatekeeping" may be diminished by recruiting the physician who served previously as the beneficiary's "usual source of care" to assume the role of formal gatekeeper. This study examines how persons whose gatekeepers were their regular source of care before plan implementation differed in their use and satisfaction from persons required to change their regular source of care. Our findings indicate that satisfaction was significantly higher among individuals who experienced no change in usual source of care. These individuals also tended to be less likely to use the emergency department as a source of care. Although the data are from Medicaid managed care programs, the findings may also be applicable to private sector point-of-service plans that adopt the primary care gatekeeper model.

Ambulatory Care↗
PubMed1987

The complexities of managed care: operating a voluntary system.

The implementation of state-sponsored voluntary case management programs for public assistance recipients creates provider and recipient recruiting problems that are unique to the state's economic environment, its political climate, its historic relationship with providers, its program goals, and its implementation strategies. This implementation study discusses the factors that influenced the operationalization of the Massachusetts managed care program for AFDC families. The issues of provider recruitment and recipient enrollment are examined in relation to the formal program goals of cost containment and access. The operational and bureaucratic problems the state Medicaid staff has experienced in maintaining the program evokes questions of who should administer the programs, who the best types of providers are in light of program goals, and how recipients can be enrolled in a voluntary program.

Aid to Families with Dependent Children↗
PubMed1988

Measuring quality in medical case management programs.

Private insurers and health care providers alike currently offer medical case management programs as a means of containing costs and enhancing the quality of care for patients with high-cost illnesses or injuries. Since 1986, Brandeis University's Bigel Institute for Health Policy has been involved in a project to evaluate medical case management programs. The study found that such programs have become popular because of the perception that high-cost patients are typically handled inefficiently. The study also found that greater attention needs to be given to developing systematic ways to measure and monitor the quality of the case management process and its effect on outcomes.

Catastrophic Illness↗
PubMed1988

Incantations in the dark: Medicaid, managed care, and maternity care.

Public program reforms in the 1980s have substantially increased the numbers of poor pregnant women potentially eligible for Medicaid coverage. Structural deficiencies in the Medicaid program, together with inadequate arrangements in managed-care plans, however, have not led to generally acceptable levels of maternity care. Demonstration projects indicate that Medicaid can be modified cost effectively to underwrite early, continuous, and comprehensive care delivery. Recommendations are suggested for eligibility guarantees, enrollment safeguards, benefit and treatment protocols, provider recruitment, quality control, and sufficient payment rates to overcome barriers to adequate levels of material health care.

Delivery of Health Care↗
PubMed1991

Measurement and management of quality in managed care organizations: alive and improving.

Leatherman et al, Schlackman, and McGuirk-Porell et al all provide important examples of how managed care organizations (MCOs) will measure quality in this decade (except for health care status, which none have yet incorporated). All three organizations rely on insurance claims as a data source and quality management as a tool for improving quality; United Health Care and US Health-care use claims data to improve care for the entire membership, a still unrealized potential for MCOs. All three programs, relatively new, can be only minimally evaluated in terms of measurement validity, cost-efficiency, and improvement in the quality of care. The impact of such MCOs depends on policy initiatives, improvements in outcome and process measures, and MCOs' commitment to serve the total population, including the uninsured and Medicaid populations.

Health Services Research↗
PubMed1990

Two approaches to measuring quality in medical case management programs.

In a study of the quality of care in a medical case management program, five physician experts, applying criteria to medical records, found the care provided appropriate in a majority of 40 cases (10 each of head injury, spinal cord injury, high-risk infants, and AIDS). Nurses interviewing parents of 30 high-risk infants found general satisfaction with case management.

Adaptation, Psychological↗
PubMed1991

Quality screening and management using claims data in a managed care setting.

Quality screening and management (QSM), developed by United HealthCare Corporation for its own health plans but applicable to other settings, analyzes health care provided to an enrolled population using claims and administrative data supplemented, when necessary, with medical record review. For selected topics/conditions, QSM compares the care received by patients to that recommended by established practice guidelines and also reports and describes quality through incidence rates, condition-specific process and outcome measures, occurrence of adverse events, and use of preventive services. Results of the analyses are linked to appropriate quality management actions and are used to identify strategies for improvement. Data permit health plans to make performance comparisons on individual indicators and longitudinal comparisons on the effectiveness of quality improvement initiatives.

Humans↗
PubMed1990

Managed care and the reorganization of Navy medicine.

Reports completed in 1988 by the Navy Inspector General and a Blue Ribbon Panel evaluated Navy medicine. They found serious problems and expressed dissatisfaction with both the organization and effectiveness of management. These findings formed the basis for a reorganization that was recommended to the Vice Chief of Naval Operations. A program of managed care was proposed to help control costs. The reorganization establishes a partnership between line officers, who will have command over medical facilities, and a more specialized healthcare establishment that will focus on resource planning and providing quality care.

Cost Control↗
PubMed1989

Economics of practice and inpatient care.

The nature and structure of inpatient psychiatric services are rapidly evolving. This article identifies and explores how these changes are being influenced by four interrelated areas: rapid growth in general and private hospital psychiatric practice; increased connections of public, private, and voluntary sectors of care; the emergence and quick acceptance of capitated and managed care programs; and dramatic change and growth in the insurance industry. These four interrelated areas further the development of a two-tier system in psychiatry: one for those with insurance, and one of the poor and the severely disabled. The changes in these four areas have also led to greater demand for increased economic competition among services, and new alliances and innovations in the delivery of treatment. This article discusses how the four areas have combined to support a two-tier system and how they are likely to affect the future evolution of general and private hospital inpatient psychiatric practice.

Cost Control↗
PubMed1990

Is solo practice really dead?

For years, the demise of solo practice has been predicted as a consequence of the corporatization of health care, the rise of managed care programs, and the creation of preferred provider organizations (PPOs). The predictors of the demise are leaders in the health maintenance organization (HMO) and PPO movement and therefore have much to gain if solo practice dries up. A survey of a random sample of licensed psychologists in New Jersey was conducted to determine the current state of private practice. A 58% return of the anonymous questionnaire revealed that 87% were in solo practice; 90% were not members of any PPO; 92% received either no referrals or less than 5% from HMOs; and 92% indicated that their referral rates and practices have either stayed the same or increased in the past three years. Clearly the predictions as far as New Jersey goes are wrong! The findings are discussed in terms of economics, humanistic concerns, and political concerns.

Cost-Benefit Analysis↗
PubMed1992

Government, private health insurance, and the goal of universal health care coverage.

The Health Insurance Association of America advocates joint efforts by federal and state governments and the private sector to achieve the goal of universal access to health care. It recommends several changes in the small employer market to provide greater predictability and protection to those insured, including establishment of private, not-for-profit reinsurance organizations authorized by the states. State risk pools for uninsurable individuals who are not part of an employer group are also proposed. The federal government role would include expanding Medicaid eligibility and exempting all insured plans from state mandated benefits. HIAA's proposal also stresses the continued growth and use of managed care programs.

Cost Control↗
PubMed1991

Intensity of in-hospital care for persons with AIDS.

We evaluated the intensity of medical care for 30 consecutive AIDS patients at one hospital, using methodology based on the Delay Tool of Selker et al. Of 25 AIDS patients who survived hospitalization, 15 had at least one delay day in the hospital. Major factors associated with care that could have been provided at an alternative site included difficulty with skilled nursing facility placement in 20% of the patients, difficulty coordinating out-of-hospital care in 28%, and scheduling of outpatient surgical procedures in 12%. For the 15 patients who could have received some of their care at a lower intensity setting, a median of 7 hospital days could have been potentially saved with better coordination of outpatient care and increased availability of skilled nursing facilities. The five patients who died in hospital also used large amounts of resources and had long lengths of stay. Prior studies of non-AIDS patients revealed similar results, suggesting that, for reasons of quality of care, quality of life, and economics, policy-makers must develop managed care programs, skilled nursing facilities that accept AIDS patients, inpatient psychiatry facilities, and increased hospice availability.

Acquired Immunodeficiency Syndrome↗
PubMed1990

Development of clinical and economic prognoses from Medicare claims data.

Using a 5% nationally random sample of Medicare beneficiaries, we calculated the probability of dying, the probability of being readmitted, and the mean level of inpatient hospital expenditures within various time periods following discharge for those beneficiaries who were discharged alive from an acute-care hospital during 1983. We then examined the 674 most common principal discharge diagnoses and found significant variations by diagnosis code for all three outcomes. We believe that analyses of claims data by diagnosis code can provide useful information to clinicians and their patients regarding the clinical and economic prognosis of specific diseases, help managed-care programs identify patients likely to incur substantial costs over a several-year period, and inform insurers regarding the expected level of resources that will be used following discharge for patients with specific diseases.

Health Expenditures↗
PubMed1988

Identifying catastrophic psychiatric cases. Targeting managed-care strategies.

Case management programs, a specialized form of utilization review (UR), focus their interventions on catastrophic cases, which comprise the minority of patients while accounting for the majority of costs. Many case management programs base their case identification and review criteria on diagnosis alone, although research has shown that it is a poor predictor of length of stay. Using claims data from a large nationwide insurer, the authors developed an empirical approach to identifying potentially catastrophic cases. The findings suggest that, in addition to diagnosis, other factors such as age and treatment setting contribute to long stays and high costs and thus should be used to identify catastrophic cases for case management interventions. Strategies to target case management programs must be considered not only in light of their impact on cost but on the quality of care for individual patients.

Adolescent↗