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PubMedDate not supplied

The impact of a high-risk disease management program on perinatal outcomes in a managed care organization.

Improvements in technology have increased the chances of survival for the micropremature infant and the very low birth-weight infant but have significantly increased the financial burden of health care organizations. This economic burden has a significant impact on third-party payers and on society in general. Of the annual US 10.2 billion dollars spent on newborn care alone, 57% is disproportionately consumed by the 10% of infants who are born preterm.

Case Management↗
PubMed1994

Common road blocks to national accounts pharmaceutical programs.

The large managed care customer represents concentrated purchasing power and product access to a large patient population. Contracting will continue to grow, and a large portion of product purchases will be under the agreements negotiated, implemented, and supported by the pharmaceutical company's national accounts department. The national accounts department will need to receive support from the organization if it is to do the job successfully.

Contract Services↗
PubMed2003

Medicaid program; external quality review of Medicaid managed care organizations. Final rule.

This final rule establishes requirements and procedures for external quality review (EQR) of Medicaid managed care organizations (MCOs) and prepaid inpatient health plans (PIHPs). It defines who qualifies to conduct EQR and what activities can be conducted as part of EQR. In addition, under certain circumstances, this rule allows State agencies to (1) use findings from particular Medicare or private accreditation review activities to avoid duplicating review activities, or (2) exempt certain Medicare MCOs and PIHPs from all EQR requirements. Also, this rule allows the payment of enhanced Federal financial participation (FFP) at the 75 percent rate for the administrative costs of EQRs or EQR activities that are conducted by approved entities.

Humans↗
PubMed1995

Preserving and strengthening Medicare.

Any restructuring or reform of Medicare should first and foremost preserve the integrity of the program. Contrary to current rhetoric, Medicare offers mainstream medical care for the most difficult-to-insure Americans, and over the past ten years its record of holding down costs has been better than that of the private insurance sector. For the very long term, when demographic changes place even greater pressures on Medicare, all dimensions of the program need to be considered in the search for a long-range solution, including asking beneficiaries and/or taxpayers to contribute more to the program. Expansion of managed care choices should certainly be part of any restructuring, but careful attention to improving the basic fee-for-service Medicare program--which will continue to serve a majority of beneficiaries for many years to come--also is needed.

Cost Control↗
PubMed2001

The effectiveness of CAHPS among women enrolling in Medicaid managed care.

The large-scale transition of public health insurance programs to managed care has shifted much of the responsibility for selecting appropriate coverage to beneficiaries--a role for which many have had little preparation. This study evaluates the impact of a CAHPS (Consumer Assessment of Health Plans Study) health care report card in assisting newly enrolled Medicaid case heads in selecting a managed care plan. The major finding is that the CAHPS report card helped consumers make more informed decisions. Those who received the report cards found judging quality between plans easier, felt that they had significantly more information on which to make decisions, and recognized the importance of their decision more often than those receiving only standard enrollment packets.

Adult↗
PubMed2000

Impact of disseminating quality improvement programs for depression in managed primary care: a randomized controlled trial.

CONTEXT: Care of patients with depression in managed primary care settings often fails to meet guideline standards, but the long-term impact of quality improvement (QI) programs for depression care in such settings is unknown. OBJECTIVE: To determine if QI programs in managed care practices for depressed primary care patients improve quality of care, health outcomes, and employment. DESIGN: Randomized controlled trial initiated from June 1996 to March 1997. SETTING: Forty-six primary care clinics in 6 US managed care organizations. PARTICIPANTS: Of 27332 consecutively screened patients, 1356 with current depressive symptoms and either 12-month, lifetime, or no depressive disorder were enrolled. INTERVENTIONS: Matched clinics were randomized to usual care (mailing of practice guidelines) or to 1 of 2 QI programs that involved institutional commitment to QI, training local experts and nurse specialists to provide clinician and patient education, identification of a pool of potentially depressed patients, and either nurses for medication follow-up or access to trained psychotherapists. MAIN OUTCOME MEASURES: Process of care (use of antidepressant medication, mental health specialty counseling visits, medical visits for mental health problems, any medical visits), health outcomes (probable depression and health-related quality of life [HRQOL]), and employment at baseline and at 6- and 12-month follow-up. RESULTS: Patients in QI (n = 913) and control (n = 443) clinics did not differ significantly at baseline in service use, HRQOL, or employment after nonresponse weighting. At 6 months, 50.9% of QI patients and 39.7% of controls had counseling or used antidepressant medication at an appropriate dosage (P<.001), with a similar pattern at 12 months (59.2% vs 50.1%; P = .006). There were no differences in probability of having any medical visit at any point (each P > or = .21). At 6 months, 47.5% of QI patients and 36.6% of controls had a medical visit for mental health problems (P = .001), and QI patients were more likely to see a mental health specialist at 6 months (39.8% vs 27.2%; P<.001) and at 12 months (29.1% vs 22.7%; P = .03). At 6 months, 39.9% of QI patients and 49.9% of controls still met criteria for probable depressive disorder (P = .001), with a similar pattern at 12 months (41.6% vs 51.2%; P = .005). Initially employed QI patients were more likely to be working at 12 months relative to controls (P = .05). CONCLUSIONS: When these managed primary care practices implemented QI programs that improve opportunities for depression treatment without mandating it, quality of care, mental health outcomes, and retention of employment of depressed patients improved over a year, while medical visits did not increase overall.

Adult↗
PubMed2001

Healthy pregnancy program in a national managed care organization: evaluation of satisfaction and health behavior outcomes.

OBJECTIVE: To evaluate satisfaction with the Healthy Pregnancy Program (HPP), which was developed to educate and coordinate the care of pregnant women in a managed care setting. STUDY DESIGN: Telephone survey. PATIENTS AND METHODS: A random sample of program participants at 3 large health plans were contacted by telephone to evaluate their satisfaction with the program overall and with its components, including an educational booklet and telephone contact with a HPP nurse as needed. Women also were asked about changes in health behaviors (smoking, alcohol use, diet, and stress) resulting directly from participation in the HPP. Of 1155 eligible women participating in HPP who delivered a baby from April 1997 through March 1998, 684 completed the survey. The response rate was 59%. RESULTS: Overall satisfaction with the HPP was reported by 96% of the women, and 76% reported the 2 highest ratings of satisfaction (completely or very satisfied). Reports of satisfaction were more likely for women who entered the program early in pregnancy, who read the booklet, and who had more telephone contacts. In general, at least half of the women in each behavior category reported improving their behavior, especially if they were younger, identified as high risk, or having their first child. Verbatim comments supported the high satisfaction levels. CONCLUSIONS: The HPP is an example of a program that was developed to improve healthcare delivery in a managed care setting and, when evaluated, was found to result in highly satisfied mothers likely to improve their health behaviors.

Adult↗
PubMedDate not supplied

Medicaid's role in financing graduate medical education.

Medicaid is the second-largest explicit payer of graduate medical education (GME). All but five states pay for GME ($2.4 billion in 1998). As states rapidly move their Medicaid populations to managed care, Medicaid support for GME is subject to change. Just sixteen states and the District of Columbia carve out Medicaid GME payments from capitated rates to managed care plans and rechannel them to teaching programs. Concurrently, managed care has motivated several states to distribute Medicaid GME funds in ways more explicitly accountable to the public. Ten states require that GME payments be directly linked to state policy goals intended to vary the distribution of or limit the health care workforce.

Budgets↗
PubMed2004

Meeting the health care needs of a rural Hispanic migrant population with diabetes.

CONTEXT: There is a need for models of health care that provide accessible, culturally appropriate, quality services to the population of Hispanic migrant farmworkers at risk for or diagnosed with diabetes. PURPOSES: The purposes of this study were to describe the Migrant Health Service, Inc (MHSI), Diabetes Program, the conceptual model on which it is based, and 4 types of outcomes achieved over a 3-year period. METHODS: Types and amounts of medical services and education were studied. Qualitative data obtained from program records and documents were analyzed to determine the nature of the program. Quantitative data were used to measure outcomes of the program. FINDINGS: The multiplecomponent MHSI Diabetes Program is addressing economic, cultural, and language barriers experienced by the target population. The program provides a continuum of health services and education that meet American Diabetes Association (ADA) Clinical Practice Recommendations on diabetes. The program exposes regional health care professionals and university students from numerous academic disciplines to Hispanic farmworker culture. CONCLUSIONS: Evidence-based program management, patient care, and program evaluation are traits of this program, which offers accessible, culturally appropriate, quality health services and education to Hispanic farmworkers. The multicomponent program model has high potential for positively impacting the health of the target population.

Diabetes Mellitus↗
PubMed1999

Attitudes toward managed care and cost containment among primary care trainees at 3 training sites.

OBJECTIVE: To study the attitudes of entering first year (Y1) and graduating third year (Y3) primary care physician trainees from 3 different training program sites (a university hospital system site [UHS], a large staff-model health maintenance organization managed care system site [MCS], and a large public hospital system site [PHS]) toward selected aspects of managed care. DESIGN: A self-administered questionnaire was used in a cross-sectional study. PARTICIPANTS AND OUTCOME MEASURES: Participants were all Y1 and Y3 primary care trainees in internal medicine, pediatrics, and family medicine programs from 3 training program sites. Survey questions dealt with attitudes toward health services, managed care cost containment, and the role of the physician in society. RESULTS: Of eligible primary care trainees (n = 218), 91% completed the instrument. Trainees at the MCS generally held more positive views of managed care systems than trainees at the UHS or PHS. Internal medicine trainees held more negative attitudes towards managed care systems than trainees in pediatrics or family medicine. UHS and PHS trainees more often thought that managed care systems interfere with the doctor-patient relationship and that these systems are more concerned with economics than in providing quality patient care. Approximately one quarter of the Y1 trainees at all sites thought that reducing the cost of healthcare is beyond the control of doctors. No Y3 trainee at the PHS believed that reducing costs was beyond the control of doctors. The majority of trainees endorsed routine peer review of clinical decisions to control healthcare costs. Most trainees believed that managed care systems will eventually predominate and that physician independence is being impaired. CONCLUSION: The data suggest that attitudes of internal medicine, family medicine, and pediatric trainees toward various aspects of managed care vary not only by their year of training but also by their training environment. Thus, managed care educational programs for trainees should consider both the baseline attitudes of trainees and characteristics of the training site itself.

Attitude of Health Personnel↗
PubMed2004

Health care delivery in the Texas prison system: the role of academic medicine.

Faced with explosive growth in its prison population and a legal mandate to improve medical care for incarcerated offenders, the state of Texas implemented a novel correctional managed health care program in 1994. The organizational structure of the program is based on a series of contractual relationships between the state prison system, 2 of the state's academic medical centers, and a separate governing body composed of 9 appointed members, which include 5 physicians. All medical, dental, and psychiatric care for more than 145,000 offenders, incarcerated under the jurisdiction of the Texas Department of Criminal Justice, is provided by the University of Texas Medical Branch and Texas Tech University Health Sciences Center. The health delivery system is composed of several levels of care, including primary ambulatory care clinics in each prison unit, 16 infirmaries at strategic locations throughout the state, several regional medical facilities, and a dedicated prison hospital with a full range of services. Specialized treatment programs have been established at various units for patients with chronic conditions, such as hypertension, diabetes mellitus, major psychiatric disorders, hepatitis, and human immunodeficiency virus infection. Significant improvements in health outcomes have occurred since the managed care program was established.

Academic Medical Centers↗