Current concepts review. Managed care: form, function, and evolution.
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Health Maintenance Organizations↗
SEARCH · PubMed Health
Results for “Managed Care Programs”
Explore indexed PubMed citations for clinical trials, systematic reviews and public health research. Read source abstracts and follow each citation to its original PubMed record.
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Room-to-grow: responding to community cultural needs to support positive parenting.
Preventive services to assist parents to understand their children's developmental needs and to devise positive, culturally appropriate strategies for managing them are not recognized as important by most third party health service payers, especially managed care programs. Room-To-Grow is an intervention designed to meet identified community needs in a culturally appropriate and sensitive way. This article discusses the evolution of this intervention and the problems encountered in finding appropriate reimbursement streams.
Community Health Nursing↗
The role of information systems in the era of managed care: an interview with Cary Sennett. Interview by Mark Bard.
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Efficiency, Organizational↗
Technology snafus. Mergers don't always compute.
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Health Facility Merger↗
Restructuring public mental health and substance abuse service systems.
The authors originally circulated the concepts in this proposal during May 1995. The purpose was to support an open, public dialogue regarding the restructuring of the mental health and substance abuse services in Illinois in anticipation of Medicaid funding changes. Restructuring mental health and substance abuse service systems should follow certain key principles. These principles are applicable to other states, particularly those large in territory and population. The authors propose the temporary use of multiple managed care companies serving as administrative services only (ASO) organizations, each of whom would have responsibility for a given geographic portion of a state. The role of the ASOs would be to organize providers into networks on a regional basis and transfer managed care expertise in financing and clinical management to the relevant state departments and provider groups. Changes in the service delivery system would be phased in over time with reorganization of key components of the system during each phase. Where the provision of mental health, substance abuse, and social services is split among multiple state agencies, these agencies would be merged to achieve unified funding and administrative efficiency. Patients and advocacy organizations would play a key role in overseeing and shaping system restructuring at all levels, including a governmental board reporting to the governor, overseeing ASO organizations' operations and assuring quality and access at the provider level. The authors propose funding of public behavioral health services through use of a tiered, integrated funding model.
Case Management↗
Why managed care demands information technology.
In health care, the only constant is change. Increasingly, information technology (IT) is becoming the primary means by which health care organizations manage the constant volatility they face. This article delineates several managed care trends driving the move to open systems and increased technologic flexibility. Changing models of care are creating a new breed of interdisciplinary, interoperable, and outcomes-focused clinical information systems.
Humans↗
Benefits of a mobile, point-of-care anticoagulation therapy management program.
BACKGROUND: Current guidelines recommend anticoagulation therapy for a number of medical conditions, but this therapy also has the potential for serious complications, particularly bleeding complications. Maintenance of anticoagulation within a narrow therapeutic window usually entails frequent monitoring with a blood test called the international normalized ratio (INR). Anticoagulation therapy management (ATM) clinics lead to improvements in quality of care, in terms of improved INR control and reduced complications. This study examined the impact of a mobile multisite, office-based ATM program that operated in seven cardiology offices in all three counties in Delaware. ATM PROGRAM: The ATM program was managed by a trained nurse who rotated among all seven offices. Patients made office visits to the nurse and received patient education, point-of-care INR testing, and medication adjustment based on a physician-approved algorithm. METHODS: This retrospective cohort study compared INR levels in the year before (May 1998-Apr 1999) and the year after (Aug 1999-Jul 2000) the start of the ATM program. RESULTS: From the year before to the year after implementation of the ATM program, the percentage of in-range INRs increased from 40.7% to 58.5% (p < 0.001). The percentage in the modified target range also increased (50.0% to 62.9%, p < 0.001). DISCUSSION: This study demonstrates the positive impact of a statewide office-based ATM program. If similar programs could be implemented in other networks of specialty offices or primary care offices, they could have a significant benefit to quality of care for patients who require anticoagulation therapy.
Adolescent↗
Impact of a decline in Colorado Medicaid managed care enrollment on access and quality of preventive primary care services.
BACKGROUND: Beginning in 1997 the Colorado Medicaid program de-emphasized managed care and shifted children from enrollment in a health maintenance organization (HMO), which required an enrollee to have an assigned primary care physician, to either the unassigned fee-for-service (UFFS) program in which the enrollee was not required to have a primary care physician (PCP) or to the primary care physician program (PCPP) in which the enrollee was required to select a participating PCP if one was available. The proportion of Medicaid enrollee-months in HMOs dropped from 75.4% in 1997 to 29% in 2003, whereas the proportion of enrollee-months in UFFS programs during this time period increased from 18.6% to 45.6%, and the proportion in the PCPP increased from 5.5% to 25.3%. This shift of children from HMO managed care to the UFFS program provided a natural experiment to assess the impact of not having an assigned PCP on pediatric primary care services. OBJECTIVE: We sought to assess whether an elective shift of children from Medicaid HMO managed care plans with an assigned PCP to the UFFS program without an assigned PCP restricted access to a primary care medical home, recommended health supervision visits, and age-appropriate immunizations. METHODS: Published Colorado Health Plan Employer Data and Information Set (HEDIS) data for 1999-2003 were reviewed to determine if Colorado children enrolled in Medicaid managed care programs with an assigned PCP (HMO and PCPP) compared with the UFFS program were more likely to have any type of visit with a PCP, to have recommended health supervision visits, and to be fully immunized. In the analysis, "HMO total" refers to the average of all children participating in HMO plans. Kaiser Permanente was considered a benchmark because it had the highest immunization rates of all HMOs. "Total Colorado" refers to the average of all children enrolled in Medicaid including the managed care and UFFS options. For 2-year-olds, the 4:3:2:1:1 combination immunization included 4 diphtheria-tetanus-acellular pertussis vaccines, 3 oral poliovirus vaccines or inactivated polio vaccines, 2 hepatitis B vaccines, 1 Haemophilus influenzae type b vaccine, and 1 measles-mumps-rubella vaccine. RESULTS: In 1999 the percentages of children 12 to 24 months of age having any type of visit with a PCP were >80% for the PCPP, Kaiser Permanente, and UFFS programs. However, although the proportion with any visit remained >85% in 2001 for children enrolled in the PCPP and Kaiser Permanente program, the percentage dropped 13.9% to 66.2% for children in the UFFS program. In 2001 the percentage of children with any type of PCP visit enrolled in the UFFS program (66.2%) was significantly lower than the total Colorado (73.6%) as well as the PCPP (85.7%) and Kaiser Permanente program (97.7%). Children 12 to 24 months of age enrolled in the PCPP in 2001 were 1.3 times more likely to have any type of visit with a PCP compared with those enrolled in the UFFS program. Children in the PCPP in 2001, 2002, and 2003 were 1.4, 1.9, and 2.6 times more likely, respectively, to have all 6 of the recommended health supervision visits compared with children enrolled in the UFFS program. Children 3 to 6 years old in the PCPP in 2001, 2002, and 2003 were 1.3, 1.5, and 1.4 times more likely, respectively, to have an annual health supervision visit compared with children enrolled in the UFFS program. In 1999, 2001, 2002, and 2003 2-year-old children enrolled in the PCPP were 2.0, 1.4, 1.5, and 1.8 times more likely, respectively, to be up-to-date with 4:3:2:1:1 vaccines compared with children enrolled in the UFFS program. In 1999, 2001, 2002, and 2003 adolescents enrolled in the PCPP were 1.8, 1.6, 1.3, and 1.6 times more likely, respectively, to be up-to-date with 2 measles-mumps-rubella vaccines compared with children enrolled in the UFFS program. CONCLUSIONS: This study documents the diminishing ability of the Colorado Medicaid program to provide children access to the benefits of a medical home, including visits with PCPs, recommended health supervision visits, and immunizations as care was shifted to the UFFS program from HMO managed care. The high up-to-date immunization rates achieved by Kaiser Permanente suggest that differences in immunization rates reflect the effectiveness of the care processes rather than the characteristics of the Medicaid population.
Child↗
The house that managed care built. Software programs generate data providers need.
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Costs and Cost Analysis↗
Baltimore's consumer ombudsman and assistance program: an emerging public health service in Medicaid Managed Care.
OBJECTIVES: To present Baltimore City Health Department's (BCHD) experience in developing and operating an ombudsprogram for Maryland's Medicaid Managed Care HealthChoice Program as an innovative public health response to its MCH Title V assurance functions. METHODS: This paper presents a case study that 1) describes Baltimore City's Consumer Ombudsman and Assistance Program (COAP) in terms of development, function, structure, and resources; 2) provides a summary of its first 30 months' experiences, both quantitatively and qualitatively; and 3) describes COAP's successes, value, and limitations with respect to its three essential roles--a) conflict resolution for individuals, b) education for consumers, providers and advocates, and c) catalyst for quality improvement. OUTCOMES: Over 1300 cases (involving enrollment, access, billing, and treatment issues) were referred to COAP by the State's Complaint Resolution Section during the first 2 1/2 years of HealthChoice. Ombudsman interventions resulted in conflict resolution for enrollees using a continuum of education, mediation and advocacy, and in generating systematic data for systems change through collaboration with state and community public health, managed care organization, provider, consumer, and advocacy officials and groups. CONCLUSIONS: Public health ombudsprograms can effectively assist and educate enrollees; and provide concurrent, or real-time, information for consumer, provider, health plan, and advocacy groups, as well as public policymakers and legislators to better inform systems improvement and innovation. The community-based ombudsman role is an effective mechanism to ensure appropriate care for MCH populations and others with special needs. Such efforts can be funded by federal/state Medicaid administrative funds and are a sound investment in assuring access to comprehensive care for vulnerable populations.
Adolescent↗
The managed care contract: the blueprint for monitoring agreements.
Healthcare providers generally undertake monitoring programs of managed care arrangements as a way of analyzing financial performance, uncovering lapses in contractually mandated performance that might expose the organization to financial loss, and gathering information that can be helpful in renegotiating the contract or negotiating new arrangements. To secure access to the information needed to achieve these goals, the provider should ensure that the contract spells out the information required, the health plan's obligations to supply this information, and the consequences of the plan's failure to meet those obligations. Such consequences may include financial penalties for the plan and special termination rights for the provider. Without a contractually explicit assurance that the needed information will be available, a provider may find itself with no way to achieve its contract-monitoring goals.
Contract Services↗
Child care health consultation programs: barriers and recommendations.
OBJECTIVES: While many studies describe the need for health services in early care and education (ECE) settings and the role of child care health consultants (CCHCs), little information exists about the challenges to developing health consultation programs. The goal of this paper is to provide insight for the development of current and future child care health consultation programs by describing the barriers identified by CCHCs related to program implementation in 20 California counties. METHODS: Forty-four child care health consultants participated in nine focus groups during their health consultation training at the California Training Institute. Participants were asked to discuss the barriers they encountered while establishing new county-wide child care health consultation programs. Themes were assigned to each response, and frequency and percentage of each theme were documented and trends were identified. RESULTS: The four general themes describing barriers to program implementation were: Program Management, Child Care Culture, Geography and Community Services. Twenty additional sub-themes, including Multi-agency involvement, Chaos, Travel time, and Fragmentation, were assigned to each response. The most frequent general theme was Program Management. The most frequent sub-theme was Professional Support. CONCLUSIONS: The barriers identified by the child care health consultants can be valuable for administrators and clinicians establishing or developing child care health consultation programs. Program managers should be prepared for the unique challenges of child care health consultation and provide flexibility and support for child care health consultants.
California↗
Minimizing promotion trauma.
In the April 1983 issue of JONA, the authors identified four major causes and the costs of promotion trauma. Nursing administrators can both minimize this trauma and its unnecessary cost by building awareness of the transition process, clarifying roles and expectations, and attending to the promoted employee's needs by developing a systematic program of manager care. Such support and encouragement can help promotees achieve the expected levels of competency in a shorter period of time, with less personal anguish. This article will help nursing administrators to develop a concept of manager care buttressed with programs for orientation of new managers, skills of mentoring, and systems of monitoring.
Administrative Personnel↗
The development of a risk-adjusted capitation payment system: the Maryland Medicaid model.
This article describes the risk-adjusted payment methodology employed by the Maryland Medicaid program to pay managed care organizations. It also presents an empirical simulation analysis using claims data from 230,000 Maryland Medicaid recipients. This simulation suggests that the new payment model will help adjust for adverse or favorable selection. The article is intended for a wide audience, including state and national policy makers concerned with the design of managed care Medicaid programs and actuaries, analysts, and researchers involved in the design and implementation of risk-adjusted capitation payment systems.
Ambulatory Care↗
Public-sector managed behavioral health care: I. Developing an effective case management program.
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Adult↗
Survey search: prevalence/effects of newer mental health care and cost management programs.
Three types of programs are beginning to capture the imagination of employers concerned about issues related to mental health care and its costs: utilization review, particularly via psychiatric PPOs and case management; Employee Assistance Programs; and substance abuse testing. The spread of these programs, the promise and problems they present and their effectiveness (where measured on a wide scale) are documented here, based on studies by a variety of researchers.
Data Collection↗
Structuring the design and implementation of leadership and teamwork for program management.
Health care providers throughout Canada are aspiring to improve how they manage their resources, while maintaining or improving the quality of patient care through more patient-focused, team-based approaches. Many of the current program management models being implemented in the field are designed to realize these aspirations. Yet they are actually opposing them because of a lack of clarity about accountability and authority. Working relationships (teamwork) within clinical teams, and between clinical teams, physicians, support functions and the senior management committee, have been vague. This lack of clarity in role relationships has created many problems. This article demonstrates how we attempted to solve some of these problems at the Royal Ottawa Health Care Group.
Guidelines as Topic↗
The changing marketplace: are subacute care providers ready?
In 1995, subacute care providers focused much attention on program development, marketing, managed care contracting and outcomes measurements. As the move to balance the federal budget continues to occupy center stage in the health care arena, subacute care providers need to rapidly shift gears and develop a blueprint for managing the changing marketplace. Without such a blueprint, subacute care providers may find themselves struggling for survival in the years ahead, instead of strategically positioned to remain competitive.
Health Facility Merger↗