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PubMed1997

The treatment of dangerous patients in managed care. Psychiatric hospital utilization and outcome.

The legal criteria for civil commitment dictates that individuals must be mentally ill, and either a danger to themselves, a danger to others, or substantially impaired in their ability to provide for their basic needs. These criteria, which have been adopted as medical necessity criteria by managed care programs, may result in a change in the clinical mix of the psychiatric inpatient population. The present study assesses the incidence of dangerousness among psychiatric inpatients and compares dangerous and nondangerous patients in terms of characteristics and treatment outcomes. The results indicate that for a large regional managed care program, 30% of psychiatric inpatients have a history of dangerousness in the past year. Patients who are rated as dangerous to others during admission have higher rates of complications for treatment and psychiatric disorders such as residential and vocational instability, family disruption, and higher premorbid dysfunction. They are also more likely to engage in disruptive and aggressive behavior during their hospital stays. Despite the higher incidence of acute and long-term dysfunction for dangerous patients, their hospitalization length of stay was comparable to that of patients not rated as dangerous.

Adolescent↗
PubMed1990

Managed mental health care: myths and realities in the 1990s.

Managed care may be viewed as the most recent attempt to control the rate of increase of health and mental health care costs in the United States. The majority of people who receive insured mental health services do so through some form of managed care program. Now increasing concerns are being raised about whether managed care really reduces costs, whether it adversely affects the quality of care, and whether it restricts access to care. The author discusses the origins, actors, and major issues involved in managed health care in terms of prevailing myths and future realities. He calls for more and better research to answer important clinical and policy questions about managed care and for improved communication between mental health professionals and managed care organizations.

Health Maintenance Organizations↗
PubMed1988

Determinants of provider selection or assignment in a mandatory case management program and their implications for utilization.

Mandatory managed-care programs for Medicaid beneficiaries typically require enrollees to select the provider who will act as gatekeeper to the medical care system. A substantial number of beneficiaries, however, do not exercise this choice and are assigned a gatekeeper. Using consumer survey data from the Missouri Managed Health Care Project, we examined characteristics and use experiences of assignees compared with selectors. We found that the assignees enjoyed better health than the selectors and were less likely to have had a regular source of care prior to the program. The utilization experience was similar for both groups. We conclude that the basis for not making a choice is one of indifference.

Adult↗
PubMed1991

An academic medical center's experience with mandatory managed care for Medicaid recipients.

This paper reports on The Hospital of the University of Pennsylvania's experience and concerns as a participating primary care site in a Medicaid managed care program (HealthPASS), which was established in 1986. Enrollment is mandatory for approximately half of Philadelphia's medical assistance population. Participating primary care sites receive monthly capitation for enrollees and serve as "gatekeepers" for specialty and inpatient services. The report discusses why the academic medical center chose to participate in the program and how existing activities were modified to meet both increased demand for primary care and increased administrative requirements. It also identifies characteristics of the HealthPASS program and of the medical center that have impeded effective case management of care for the urban poor population that the program serves. Improving the quality of care for the medically indigent while controlling costs is essential, but political realities and the special needs of the Medicaid population must be acknowledged. Increased attention must be given to the impact that political compromises have on the design and effectiveness of a managed care program.

Academic Medical Centers↗
PubMedDate not supplied

Risk factors for antihypertensive medication refill failure by patients under Medicaid managed care.

Antihypertensive medication noncompliance is common and leads to substantial morbidity for patients and increased health care costs for managed-care organizations. A retrospective cohort study using pharmacy prescription profiles to estimate noncompliance was conducted to determine important risk factors for patient noncompliance with antihypertensive therapy for Medicaid enrollees participating in a managed-care plan. The pharmacy and claims data for 1395 patients with uncomplicated hypertension who were enrollees of Tennessee's Medicaid managed-care program were analyzed to determine the frequency of the enrollees' failure to obtain timely antihypertensive medication refills (hereafter referred to as refill failure) and to identify the predictors of refill failure. Overall, refill failure occurred in 33% of 7413 refill opportunities studied, whereas refill failure occurred in 32% of the cases in which medication was dosed once daily and in 35% of the cases in which medication was dosed more than once daily. For patients taking alpha-blockers, there was a significantly lower rate of refill failure (11.0%) than for patients taking angiotensin-converting enzyme inhibitors, direct vasodilators, and thiazide diuretics. Patients taking calcium channel blockers, had a significantly lower rate of refill failure (38.5%) than for patients taking thiazide diuretics (45.5%). Younger age, medication class, multiple-daily dosing regimen, and fewer provider visits were all found to be significant independent predictors of refill failure, whereas gender and regimen complexity were not significant predictors in this population. Health care systems planning pharmacy-based interventions to improve patient compliance with antihypertensive medication for patients in a Medicaid managed-care program can expect to encounter high levels of refill failure and may want to target enrollee subgroups by age, medication class, or dosing regimen for intensive intervention efforts.

Adult↗
PubMedDate not supplied

Decision matrix for selection of patients for a home infusion therapy program.

Managed care and escalating healthcare costs have affected all aspects of clinical practice. Today's practitioners must evaluate each patient and clinical situation to select the appropriate intravenous delivery venue to improve the chances of producing a satisfactory outcome. The IV venue discussed in this article will focus on the key elements of identifying patients who will benefit from receiving pharmacomedical services in a home infusion therapy program.

Drug Therapy↗
PubMed1996

Characteristics of managed care patients in a psychiatric emergency service.

Managed care programs establish procedures to help their patients avoid use of psychiatric emergency services. To determine whether managed care patients who do visit the emergency service do so primarily for hospitalization and have briefer contacts with the service because of preapproval for hospitalization, records were examined for 293 patients who visited a psychiatric emergency service; 69 were enrolled in a managed care plan. The findings did not confirm the expectations: many managed care patients received crisis services and were referred for outpatient care. The non-managed-care group had more psychotic and substance use disorders, required more emergency community intervention, and had more previous psychiatric hospitalizations.

Ambulatory Care↗
PubMed1996

Any-willing provider laws: point and counter point.

Health care costs in the United States are placing businesses in a competitive disadvantage in the international market. Health Care is now the third highest cost category in US corporations after salaries and raw materials. Alternative Health Care delivery systems in the form of managed care have become popular mechanism to promote cost control. A critical element in most managed care programs is a limitation of freedom of choice of provider. As a result, physicians are being deliberately excluded from some managed care plans. Legislation called "Any Willing Provider Statutes" is being enacted in many areas to prohibit such actions. The authors outline the advantages and disadvantages of such legislation and discuss the economic implications for hospitals and the private practice of medicine. They also examine the impact "any willing provider" legislation will have on patient care and detail how this legislation involves who is going to control the practice of medicine in the years ahead. An examination of the American model should assist others involved with health care planning and regulating medical practice.

Consumer Advocacy↗
PubMed1997

Predicting readmission to the psychiatric hospital in a managed care environment: implications for quality indicators.

OBJECTIVE: This study examined predictors of hospital readmission to determine whether readmissions can serve as a quality indicator for an inpatient psychiatric service. METHOD: A series of 255 patients consecutively admitted to any of seven psychiatric hospitals in a regional managed care program were followed to determine whether they were readmitted within 6 months of discharge. Case managers assessed patients with the use of a reliable outcome management/decision support system designed for acute psychiatric services. RESULTS: Patients with greater impairment in self-care, more severe symptoms, and more persistent illnesses were more likely to be readmitted than other patients. Suicidal patients were less likely to be readmitted. There was no evidence to suggest that poor hospital outcome or premature discharge was associated with readmission either within 30 days or within 6 months. CONCLUSIONS: Although patients at risk for hospital admission can be identified, it does not appear that the success of the hospital intervention per se influences the likelihood of readmission. Use of readmission rates as quality indicators for hospital care providers is not recommended.

Acute Disease↗
PubMed1994

Compensation of radiologists.

The compensation of radiologists for professional services to patients has shifted in the past half century from a strong reliance on hospital billing and payment to a pattern of financial independence of radiology groups. The laws and regulations creating the Medicare program were instrumental in spurring the transition for many. With the advent of managed care programs, employer self-insurance for health costs and pending state and federal health reform efforts, radiology compensation patterns are likely to undergo further changes to make them compatible with new payment mechanisms.

Fees, Medical↗
PubMed1995

General hospital psychiatry and the ethics of managed care.

Managed care programs come in many stripes, and the field is evolving with bewildering rapidity. In order to be effective advocates and critics, clinicians need a vision of ethical managed care practice, to use as a standard for judgment and quality improvement. This paper presents four principles that I believe capture the essential stance of an ethical clinician in managed care. The central challenge for creating ethical managed care systems is integrating stewardship (communitarian) and fiduciary (patient centered) values. Because general hospital psychiatrists treat individual patients in a "communal" (institutional) setting in which issues of resource use stand out with great clarity, they will play a central role in developing ethical guidelines for managed care practice. This paper considers issues in general hospital psychiatric practice--determining hospital length of stay, deciding how much suicidal risk is tolerable in a treatment plan, and the problems that arise when patients prefer valid but less cost-effective treatments--as examples of the kinds of questions a clinically relevant set of ethics must address.

Cost-Benefit Analysis↗
PubMed1997

What is influencing performance improvement in managed care?

Both consumers and providers alike are concerned about quality in the managed care environment. Performance improvement activities frequently focus on preventive health measures, provider access, and availability of service. What is the the driving force? The article provides an overview of external reporting requirements of purchasers of health care, accrediting bodies, and regulatory agencies that are influencing quality programs in managed care.

Accreditation↗
PubMed1992

Healthchoice: a managed health-care program for low-income uninsured workers.

The period in which we practice medicine is unprecedented in terms of the enormous changes that are taking place within the profession. Perhaps foremost among the changes is the manner in which the practice of medicine is organized. Historically, over the last 30 years we have witnessed the transition of substantial proportions of physicians as solo practitioners to professionals employed in one form or another by institutional management care systems. Further, from all indications, this change is continuing unabatedly. There are now more than 600 health maintenance organizations (HMOs), and their enrollment rates have been steadily increasing. More than 60 million Americans or about 30% of the insured population receive their medical care through HMOs and preferred provider organizations (PPOs). Moreover, it is estimated that in the year 2000, 90% of all Americans will be receiving their medical care from managed care systems. Clearly, the driving force behind these changes is the desire of third-party payers and the public at large to control health-care costs. We, of course, share this goal and are committed to working with the public and private sectors to accomplish this aim. Deborah L. Scott, director of the Wayne County Patient Care Management Systems, writes about HealthChoice, a model managed-care program in Detroit, Michigan. Ms Scott's article is being published in lieu of the President's Column.

Female↗
PubMed1995

Rehabbing Medicare. Is managed care a cure-all or just a crutch?

Money, or the prospect of saving it, is what's rallying many in Congress around supporting managed care as Medicare's magic bullet. And financial, as well as community, incentives are certainly helping to push Medicare managed care programs forward in the delivery system. But will those programs accomplish everything their advocates expect?

California↗