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PubMed1998

Competition and quality among managed care plans in the USA. Boston University Health Care Management Program Group.

This paper examines the popular idea that competition among managed care plans will lead not only to lower prices, but also to improved quality. We explore the likelihood that competition based on quality will occur and that better quality care will result. First, we discuss key elements of competitive theory and then we attempt to apply them to markets for health care coverage and care. We identify the conditions necessary for competition to have the desired effects and assess the extent to which those conditions do or can exist. We conclude that in the USA, many consumers have no choice among plans and, therefore, cannot select one based on quality. Moreover, the evidence suggests that as long as price varies among health plans, consumers who do have a choice will tend to emphasize price, not quality, in making their selections. We conclude with suggestions to increase the likelihood that quality can improve as a result of competition.

Consumer Behavior↗
PubMed2006

The effect of a medicaid managed care program on patterns of psychiatric readmission among adolescents: evidence from Maryland.

This study evaluates the effect of Maryland's Medicaid managed care program on patterns of psychiatric readmission for adolescents. Rates and frequency of readmissions are compared before (FY 1997) and after (FY 1998) the implementation of Maryland's Medicaid managed care program. Medicaid claims files were reviewed for 881 adolescents consecutively admitted to three major Maryland psychiatric hospitals between July 1, 1996 and June 30, 1998. Adolescents admitted after the managed care reforms were more likely to experience multiple readmissions. The 1-year cumulative rate of readmission pre- and postmanaged care was 33% and 38%, respectively; the highest risk period fell within the first 15-30 days postdischarge. The high rate of early readmissions raises concern about the quality of care and the adequacy of community-based services. Findings also suggest that youths with serious emotional disturbances who are high users of inpatient care may be adversely affected by the managed care reforms.

Adolescent↗
PubMed2001

Addressing challenges, creating opportunities: fostering consumer participation in Medicaid and Children's Health Insurance managed care Programs.

With more than half of the Medicaid population enrolled in managed care and with enrollment in Medicaid managed care and Children's Health Insurance Programs continuing to accelerate, policy makers and program administrators must quickly come to consensus on the role of the consumer in the planning, implementation, and oversight of Medicaid and S-CHIP managed care. This article explores the barriers to consumer participation and makes concrete policy and programmatic recommendations to increase consumer participation in public managed care programs. To fully comply with existing federal and state requirements for consumer participation and for this participation to have an impact on the quality of managed care programs, states need to provide more education and support to consumers on: how to choose a health plan; how to access the health plan services and out-of-network benefits; and how to use grievance procedures. In addition, more work needs to be done to make the growing availability of health plan and provider performance data meaningful and available to Medicaid and S-CHIP consumers. Finally, states must address the lack of resources, lack of information, and lack of training that prevent many consumers from being able to sustain their involvement in system-level advisory and oversight bodies.

Child↗
PubMed1997

Fallon ER facilitator program: managed care in the ER setting.

Managed care systems have traditionally found ER management issues difficult to address. Patients view these facilities as points of consistent, easy, and reliable care. Providers see these facilities as necessary off load points from busy practices for problems whose intensity or complexity would overwhelm their office work flow. Emergency Department physicians understand their roles as nondiscriminate passive recipients of all patient flow through their facilities. These same providers also recognize a huge liability potential for both missed diagnosis and for perceived inadequate/unsafe treatment plans such as non-hospitalization when hospitalization was needed.

Costs and Cost Analysis↗
PubMed1994

Evaluation of a managed care program for the non-Medicaid urban poor.

In 1988, Detroit and surrounding Wayne County, Michigan, began CountyCare, an innovative managed care program designed to deliver health care services to the very poor while reducing excessive emergency-room and inpatient care. We interviewed 279 former CountyCare participants to assess differences in off-program utilization, use of clinical services, hospitalization, and patient satisfaction among respondents assigned to one of four CountyCare provider groups. Patients responded favorably to CountyCare, although off-program utilization was substantial and emergency-room and inpatient care were not significantly reduced. We conclude that how such a program is managed and administered, and a provider's degree of motivation, govern the extent to which it succeeds in reducing health care costs and increasing patient satisfaction.

Adult↗
PubMed1993

Managed care programs: an employer perspective.

Throughout the 1980s, employers made many health care benefit plan modifications that were directed toward containing costs. This chapter discusses potential managed care program changes that may occur in the coming years. Specifically reviewed are partnerships between employers and managed care entities; possible features of the next generation of managed are plans; and dimensions of a cost-benefit analysis that employers could use to gauge the cost-effectiveness of future plan changes.

Cost-Benefit Analysis↗
PubMed1998

Tennessee's failed managed care program for mental health and substance abuse services.

In July 1996, Tennessee initiated a managed mental health and substance abuse program called TennCare Partners. This publicly funded "carve-out" experiment started chaotically and soon deteriorated into a crisis. Many patients did not receive care or lost continuity of care, and the traditional "safety net" mental health system nearly disintegrated. This qualitative case study sought to ascertain the impact of the TennCare Partners program. It points out that the program's difficulties stemmed directly from a flawed design that spread funds previously earmarked for severely mentally ill patients across the entire Medicaid population. States contemplating similar reforms should strive to protect vulnerable patients by risk-adjusting capitation payments and by focusing resources on care for severely mentally ill persons. States should also minimize program complexity and ensure the accountability of managed care networks for their patients' behavioral health care needs.

Adult↗
PubMed2001

A statewide assessment of lead screening histories of preschool children enrolled in a Medicaid managed care program.

OBJECTIVES: Despite the prominence of lead poisoning as a public health problem, recent Government Accounting Office reports indicate that only one fifth of children who are covered by Medicaid have been screened for lead poisoning. The purpose of this study was to examine the lead screening histories of children who were enrolled in a statewide, Medicaid managed care plan to determine the relative impact of the type of primary care provider site and family sociodemographic characteristics on the likelihood of being screened. The study also examined the prevalence of and risk factors for lead poisoning of children who had been screened. METHODS: A random sample of 2000 preschool-age children was chosen from those who were enrolled continuously in the statewide, expanded, Medicaid managed care program for a 1-year period and between the ages of 19 and 35 months at the end of that year. Sociodemographic characteristics and lists of primary care providers were obtained from administrative data sets. Medical record audits at primary care provider sites were performed to obtain the lead screening histories of the children, including test dates and results. RESULTS: Data on 1988 children were used for study analyses, and 80% of these children had at least 1 documented blood lead level. Children whose primary care provider was an office-based physician were less likely to be screened as compared with patients of health centers, hospital-based clinics, and staff model health maintenance organizations (68%, 86%, 89%, and 91% respectively). Variation in screening rates persisted in a multivariate analysis controlling for family sociodemographic characteristics and practice level variation. Of the 1587 children who had a documented blood lead test, 467 children (29%) had a blood lead level of >/=10 mg/dL on at least 1 test. CONCLUSIONS: Blood lead screening rates in Rhode Island's Medicaid managed care program are dramatically higher than national estimates for children who are enrolled in Medicaid. Potential explanations for this finding are 1) a high sensitization to the problem of lead poisoning in Rhode Island, 2) the primary care focus of the Medicaid program in Rhode Island facilitates the delivery of preventive services, and 3) the medical record audit approach used in this study was more comprehensive in identifying blood lead screens than techniques used in national studies. The high prevalence of elevated blood lead levels found in this study emphasizes the importance of screening among children who are enrolled in Medicaid.

Child, Preschool↗
PubMed2005

Medicaid managed care program provides fiscal rewards for performance.

Commercial insurers across the country are paying bonuses to physicians and hospitals that meet or exceed quality and performance goals. But now a Medicaid managed care program is using pay-for-performance incentives to prompt hospitals to take better care of its members.

California↗
PubMed2000

A survey of participation in managed care programs by endodontic specialists.

A survey was published in the Quarterly Survey of Dental Practice (QSDP) Special Topics that dealt with contractual agreements in dentistry. This survey evaluated general dental practitioner participation apart from that of dental specialists in general. The Quarterly Survey of Dental Practice survey was modified and used in the present study to specifically determine the participation by endodontists in various contractual insurance agreements, including Preferred Provider Organization and Health Maintenance Organization programs. A 10% sample of practicing endodontists was randomly selected to participate in this survey. Questionnaires (331) were sent out, and 229 or 69% were returned. Total participation by endodontists responding to this survey in any Health Maintenance Organization and/or Preferred Provider Organization insurance plans was 31.3%; however the total percentage of patients treated under these insurance plans was only 6.6%. These results were similar to those in the 1994 survey in which it was shown that 27% of the general dental practitioners and 41% of the dental specialists participated in one or more of these insurance programs and treated respectively, 5% and 9%, of their patients under these plans. Although participation in various managed care programs by endodontists in this survey was close to one-third, the total number of patients treated under these plans was low. Overall patients treated under fee-for-service arrangements by endodontists responding to this survey formed 85.3% of their patient pool. It does not appear from the results of this survey that managed care insurance has a significant impact on the practice of endodontics. It can be postulated that endodontists are unwilling to accept more than a small reduction in fees to join managed care plans, and they also desire to retain full control of their dental practice.

Analysis of Variance↗
PubMed1990

Managed care programs.

Explore the source record for details and available documents.

Health Maintenance Organizations↗
PubMed2001

The development of a palliative care program for managed care patients: a case example.

Palliative care is emerging as an important new field. Although programs are developing in hospital environments, little is known about development of programs in outpatient practices or those serving large managed care populations. This article provides a framework for the development of a comprehensive palliative care program in a large multispecialty group practice that serves managed care patients. The article addresses guiding principles, the need for obtaining baseline data, how the clinical consultation service was established, development of outcomes measures, and information on current program status. Five themes emerged as key to successful program development, most importantly the close collaboration between administrative and clinical staff in all aspects of program development.

Aged↗
PubMed2002

Well-baby care in Connecticut's Medicaid managed-care program.

OBJECTIVES: 1) To describe well-baby care in Connecticut's Medicaid managed-care program; 2) to determine the effect of well-baby care on emergency care or hospitalization for ambulatory care-sensitive conditions. DESIGN: Retrospective cohort study. METHODS: Babies born between January 1 and March 31, 2000 who were continuously enrolled for the first year of life were identified (n = 2,054). Encounter data were searched for timely well-baby visits and for emergency care or hospitalization for selected conditions. RESULTS: Thirty-four percent of infants received five or more timely visits during the first year of life. African American and Hispanic babies were less likely than white babies to have had all the recommended care (OR = 0.49, 95% CI: 0.37, 0.63; OR = 0.53, 95% CI: 0.41, 0.69; respectively). Being up-to-date with well-baby care was not associated with a reduced likelihood of emergency care (OR = 0.89; 95% CI: 0.72, 1.09) or hospitalization (OR = 1.23; 95% CI: 0.83, 1.34). CONCLUSION: Most babies did not get timely care. Well-baby care was not associated with reduced use of emergency care or hospitalization for ambulatory care-sensitive conditions.

Connecticut↗