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PubMed1998

Case management programs in primary care.

To review the impact of case management programs on health care resource use; their impact on patient satisfaction, quality of life, and functional status (patient-centered outcomes); and their cost-effectiveness, we reviewed the English language literature utilizing the following MEDLINE and HealthSTAR headings: case management, patient care planning, patient-centered care, disease management, care management, and managed care programs. Bibliographies of relevant articles were also reviewed. Only randomized controlled trials were included. Data were extracted manually from relevant publications and are presented descriptively because formal, quantitative methods were not applicable. Nine studies met our inclusion criteria. Of the seven studies examining case management's impact on health resource use, only two found a positive effect. Both successful programs targeted patients with specified disease conditions and care was supervised by a medical subspecialist. None of the programs targeting general disease conditions or supervised by generalists reported a positive effect. All six studies examining patient-centered outcomes reported a positive impact. These effects were unrelated to the patient's conditions or the study personnel. Both studies examining clinical parameters found a positive impact. Only three studies examined costs; all reported nonsignificant cost savings. While case management programs offer theoretical benefits, few examples of successful programs were found. Positive effect was related to disease condition and specialty training of study personnel. Patient-centered outcomes were often improved upon but at unknown cost. Further multisite clinical trials are needed to define case management's role in our future health care system.

Case Management↗
PubMed1991

Impact of a mandatory Medicaid case management program on prenatal care and birth outcomes. A retrospective analysis.

This study examined the impact of Philadelphia's mandatory Medicaid case management program (HealthPASS) on adequacy of prenatal care and birth outcomes among enrollees. A sample of 217 deliveries for HealthPASS patients at the Hospital of the University of Pennsylvania (HUP) during 1988 was compared with a matched sample of 1988 deliveries at HUP for whom the payor was Pennsylvania's traditional fee-for-service Medicaid program. Inpatient charts for all 434 subjects were abstracted for information on sociodemographic characteristics, substance use during pregnancy (cigarettes, alcohol, and drugs), course and extent of prenatal care, and birth outcomes including birth weight, gestational age, and mortality. No significant differences were detected between HealthPASS and Medicaid groups, suggesting that the mandatory managed care program neither improved nor impeded access to needed services. These results were not surprising in view of the fact that HealthPASS actually did little to change provider or patient behavior with respect to obstetrical care. Both the HealthPASS and Medicaid groups experienced low rates of adequate prenatal care (39%) and high rates of low birth weight (20%). Also disturbing was the finding that at least 46% of women smoked during pregnancy, at least 20% drank alcohol, and at least 17% used cocaine. These findings support the need for continued efforts to improve both access to, and content of, prenatal care for the urban poor.

Adolescent↗
PubMed1997

Pricing specialty carve-outs and disease management programs under managed care.

The drive toward improved efficiency and effectiveness in health care has spawned disease management programs to address the needs of patients with certain conditions. These programs parallel traditional case management programs in monitoring patients, but disease management differs from case management in early assessment of patient risk, with proactive clinical interventions and educational efforts. The most comprehensive programs include a coordinated delivery system that can be "carved out" from other health care benefits. Pricing disease management can benefit from the analysis of detailed, disease-specific and community-specific data from public or private sources.

Capitation Fee↗
PubMed1996

Assuring quality of care for children with special needs in managed care organizations: roles for pediatricians.

Increasing numbers of children with special health care needs are enrolling in managed care programs. Although managed care may improve service coordination and use of primary care, it may also threaten health outcomes for these children by potentially decreasing access to the range of needed services, eroding progress in developing community-based service systems, and failing to assure quality of care. To date, few frameworks have been proposed to assess quality of care for this population of children in managed care organizations. In this article, we adapt the Institute of Medicine's definition of quality and identify six key components: content of service delivery systems, the nature of desired health outcomes, risks associated with service delivery, constraints of care, interpersonal dimensions, and attention to developmental issues. These components can be assessed at three levels: the individual, the health plan, and the community. Pediatricians and other child health professionals have critical roles to play in assuring that policies and practices within managed care organizations promote a high quality of care for this vulnerable population of children.

Child↗
PubMed1998

The role of nutrition screening and intervention programs in managed care.

Nutrition screening and intervention programs provide managed care plans with an opportunity to meet the needs of the increasing Medicare risk population. Recently, representatives from various health plans came together to discuss program benefits as well as the best practices in the development and implementation of such programs to ensure successful outcomes. Through simple and cost-effective programs, health plans can improve member satisfaction, resource utilization, and the health status of their members.

Aged↗
PubMed1999

Managed care of children with special health care needs: the ABC Program.

Families of children voluntarily enrolled in a managed care program for children with special health care needs receiving SSI and Medicaid benefits and their case managers were surveyed regarding care satisfaction, quality, and access. Claims data were used to compare the cost and utilization of health care before and during program enrollment. Families rated health care quality improved in 43%, unchanged as "excellent" in 50% of cases. The care received was seen as more nearly complete and of higher quality when the provider was based in the hospital or the hospital's community clinics as compared with "private" community pediatricians. Hospitalization decreased, but no decrease in cost was demonstrated. A carefully planned and implemented managed care program can improve patient perception of quality among chronically ill children.

Child↗
PubMed1996

Diabetes and managed care: the Lovelace Health System's Episode of Care Program.

In order to efficiently manage the care of large populations, the health of that population must be evaluated. People identified with chronic medical disorders, such as diabetes mellitus, should have their disease managed proactively in the most cost-effective manner across the continuum of care. Lovelace Health System has established an Episode of Care disease management program based on the principles of clinical practice improvement. The diabetes program is described as an example of this approach to define and monitor best practice and to decrease variation among providers. This approach optimizes the use of health care resources and improves patient outcomes.

Continuity of Patient Care↗
PubMed1998

Clinical and economic impact of implementing a comprehensive diabetes management program in managed care.

Diabetes mellitus places a significant burden on the U.S. healthcare system. Because of the potential to reduce diabetic complications and costs through intensive management, diabetes has become a primary target for disease management programs. We performed a retrospective analysis of short-term baseline and follow-up clinical, economic, and member and provider satisfaction data from approximately 7,000 people with diabetes being treated through seven managed care plans using Diabetes Treatment Centers of America's Diabetes NetCare, (Nashville, TN), a comprehensive diabetes management program. Our analysis indicates that Diabetes NetCare achieved gross economic adjusted savings of $50 per diabetic member per month (12.3%), with gross unadjusted savings of $44 (10.9%) per diabetic member per month. Hospital admissions per 1,000 diabetic member years decreased by 18%, and bed days fell by 21%. Patients with diabetes were more likely to get HbAlc tests, foot exams, eye exams, and cholesterol screenings while enrolled in the program. These data suggest that implementation of a comprehensive healthcare management program for people with diabetes can lead to substantial improvements in costs and clinical outcomes in the short-term. It is expected that improvements will increase over time, with continuing improvements in health status and a reduction in the number of future diabetic complications.

Adult↗
PubMed1988

An evaluation of Utah's primary care case management program for Medicaid recipients.

One of the first case management (CM) programs for limiting Medicaid enrollees' freedom of choice of provider was established by Utah. By assigning enrollees to specific providers responsible for arranging all nonemergency care, Utah intended both to improve access and to reduce program costs. State officials expected the program to increase recipients' use of primary-care providers, while reducing their use of specialists, prescription drugs, and hospital outpatient services. Savings from reductions in unnecessary use were expected to more than offset increases in outlays arising from access enhancements, resulting in lower program expenditures. This study investigated the extent to which the state Medicaid program achieved these goals. The analysis was based on a two-part multivariate model of usage, estimated from data created from claims-level information provided by Utah. The findings revealed that the use of primary-care physician services increased significantly. However, the program also raised the use of specialists' services and prescription drugs. In contrast, the use of hospital outpatient services was lowered. Overall, CM apparently achieved the objective of increased access, but failed to attain the cost-containment goal. The findings indicated that expected costs for ambulatory care rose by 25% in the early years as a result of case management.

Cost Control↗
PubMed1996

Missed appointments and Medicaid managed care.

OBJECTIVES: To compare the demographic characteristics of patients who miss appointments with those who do not and to identify subgroups who would benefit from specific interventions for improving attendance. DESIGN: Retrospective cohort study of an 18-month period. SETTING: An urban primary care practice. PATIENTS: A random sample (N = 477) of patients who were seen at least twice during the study period. MAIN OUTCOME MEASURES: Number of missed visits and kept visits, insurer, age, sex, race, ZIP code, and diagnoses. RESULTS: Of the established patients, 48% missed 1 or more visits. Patients in managed care programs, private and Medicaid, were likely to have missed more visits during the study period than those not in managed care programs (P < .001). Medicaid managed care patients had also scheduled more visits. Significantly higher rates of missed appointments were found in patients aged 19 to 35 years (P = .02), blacks (P < .001), patients in Medicaid managed care programs (P < .001), and patients who scheduled more visits (P < .001). After adjusting for age, race, and sex, Medicaid managed care insurance remained a significant (P < .01) predictor of rate of missed appointments. CONCLUSIONS: Patients in managed care programs missed more appointments. Patients in Medicaid managed care programs scheduled more appointments and had higher rates of missed appointments than their counterparts in other insurance groups.

Adult↗