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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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At least 991 records · Page 55Linked to original sources
PubMed1998

Disease state management in diabetes care.

Diabetes affects over 16 million Americans. Caring for patients with diabetes requires extensive health care resources. Managed care organizations must utilize resources cost-effectively to survive in the health care industry. A disease state management program for diabetes may enable the managed care organization to meet its goal of providing cost-effective quality health care while meeting regulatory standards. The National Committee for Quality Assurance (NCQA) which accredits managed care organizations and provides information on performance, grants accreditation status to managed care organizations and reports favorable comparisons with competing managed care organizations.

Cost-Benefit Analysis↗
PubMed1996

Medicaid, managed care and optometry: a review.

BACKGROUND: Significant changes are restructurng the U.S. health care delivery system. National health reform is now extending itself into the public sector. Increased health and medical costs by federal and state governments are forcing a reevaluation of major entitlement programs, especially Medicaid. METHODS/RESULTS: Because Medicaid is the single largest item in many state budgets, states are now enrolling Medicaid patients into managed and coordinated care arrangements as a means to control costs and increase access to care. HMOs are not only competing for private patients but also actively seeking the Medicaid population. Nationally, almost one-fourth of all Medicaid patients are now enrolled in managed care plans. Various models and approaches have been developed by individual states. CONCLUSIONS: Because managed care enrollment in the Medicaid program has increased substantially in recent years, selected services including vision care are no longer rendered by any practitioner willing to accept Medicaid fees. Freedom of choice is now restricted to pre-selected and panel practitioners participating with the managed care program. The rules, regulations, billing procedures, fees, and program requisites will differ under managed care programs. Private optometric practitioners must consider entering economic and organizational relationships and linkages that make them attractive to managed care organizations.

Humans↗
PubMed2004

Cultural competency as it intersects with racial/ethnic, linguistic, and class disparities in managed healthcare organizations.

Culture in and of itself is not the most central variable in the patient-provider encounter. The effect of culture is most pronounced when it intersects with low education, low literacy skills, limited proficiency in English, culture-specific values regarding the authority of the physician, and poor assertiveness skills. These dimensions require attention in Medicaid managed care settings. However, the promise of better-coordinated and higher quality care for low-income and working-poor racial/ethnic populations--at a lower cost to government--has yet to be fully realized. This paper identifies strategies to reduce disparities in access to healthcare that call for partnerships across government agencies and between federal and state governments, provider institutions, and community organizations. Lessons learned from successful precedents must drive the development of new programs in Medicaid managed care organizations (MCOs) to reduce disparities. Collection of population-based data and analyses by race, ethnicity, education level, and patient's primary language are critical steps for MCOs to better understand their patients' healthcare status and improve their care. Research and experience have shown that by acknowledging the unique healthcare conditions of low-income racial and ethnic minority populations and by recruiting and hiring primary care providers who have a commitment to treat underserved populations, costs are reduced and patients are more satisfied with the quality of care.

Cost Control↗
PubMed2000

Specific clinical competencies for managing care: views of residency directors and managed care medical directors.

CONTEXT: Although medical educators recognize the need to prepare physicians to work effectively in managed care environments, managed care is often perceived negatively by academic physicians. Curricular reform has been hampered by a failure to seek agreement about specific clinical competencies that are important to both managed care directors and medical educators. OBJECTIVES: To identify specific clinical competencies in the managed care setting and to assess agreement between residency directors and managed care medical directors on the importance of these competencies. DESIGN, SETTING, AND PARTICIPANTS: Surveys (1998-1999) of a national sample of 59 residency directors involved in managed care training programs (response rate, 94%); a sample of 186 residents in these programs and 258 matched control residents (response rate, 77%); and national samples of 147 managed care organization (MCO) medical directors (response rate, 67%) and 140 primary care residency program directors in areas of high MCO penetration (response rate, 73%). MAIN OUTCOME MEASURES: Specific clinical managed care tasks as defined by residency directors; self-reported confidence in performing these tasks by sample residents vs control residents; and importance of these tasks as rated by MCO medical directors and residency program directors. RESULTS: Twenty-six specific clinical managed care tasks were identified by the residency directors. Residents who participated in managed care training were significantly more confident than their counterparts in performing 20 of the 26 tasks (P<.01 for all). Residency directors and MCO medical directors viewed 65% of these tasks as important to patient care during the next 5 years. Of the 10 tasks most highly rated by residency directors and MCO medical directors, 9 were the same, addressing time management, ethics, case management, practice guidelines, cost-effective clinical decision making, referral management, disease management, patient satisfaction, and clinical epidemiology. CONCLUSIONS: Our data indicate that residency directors and managed care medical directors value mastery of many of the same specific clinical competencies in managed care. Previously documented negative attitudes toward managed care among academic physicians may obscure an underlying concordance about the skills essential to managing the health of populations. JAMA. 2000;284:1093-1098

Administrative Personnel↗
PubMed1997

Value-based formulas for purchasing. Pursuing value in Medicaid managed care: access to care and enrollee information management.

Medicaid and other publicly funded health coverage programs face special challenges in managed care purchasing. This article discusses two of those challenges based on the state of Minnesota's experience: how to develop, evaluate, and communicate access to care; and how to manage the transfer of enrollee eligibility and health status information.

Catchment Area, Health↗
PubMed1992

The entrepreneurial physician.

This article draws on the experience of interviews of hundreds of physicians in the last few years. Those at mid-career have deep concerns about what lies ahead for them. A character, Dr. Charles Evans, has been created to describe some of the major possibilities being thought about and explored by physicians who believe their profession is now changing in ways they never had anticipated.

Defensive Medicine↗
PubMed1993

The impact of managed care on dermatology.

The goal of managed care is to find the most effective mix of the factors of production to provide quality care to its members. The aforementioned information on the impact of managed care on dermatology suggests that the future of dermatology need not be bleak. The supply of dermatologists in the nation is far more consistent with the demand of classic MCOs for dermatologists than for almost all other specialties. In addition, any form of health care reform that increases access to health care for the uninsured and underinsured will increase the demand for dermatologic care. Similarly, a well-functioning managed care plan will move to establish the boundary line between skin care by PCPs and dermatologists in a consensual, objective, and mutually respectful process. The attempt to define this boundary will give added impetus to the development of outcomes measurement and management in managed care and serve to advance the interests of all parties concerned, including the patient. A well-defined boundary line between care appropriately rendered by PCPs and that provided by dermatologists will result in dermatologists treating a higher severity of illness--the cases for which dermatologists were trained to treat. The higher level of severity of illness could be associated with a higher level of professional satisfaction. Similarly, capitated arrangements between dermatologists and PCPs create incentives for cooperative education and communication initiatives between both parties to define appropriate ranges of care and referral timing. Where capitated arrangements do not exist, it is also important to define such appropriate ranges of care.(ABSTRACT TRUNCATED AT 250 WORDS)

Attitude of Health Personnel↗
PubMed2001

Analysis of a managed psychiatric disability program.

The cost of mental illness to employers has been well documented; however, efforts to effectively reduce the costs of psychiatric disability are adversely affected by the fragmentation of health care services. This report is a case study of a program in which a managed behavioral health care organization managed the psychiatric disability of a telecommunications company. Compared with a non-random cohort of claimants not managed under the pilot, the duration of disability was reduced by 23% (17.1 days). Patient and provider satisfaction with the program was high. This study illustrates the potential for effectively reducing the cost of psychiatric disability and the challenges in coordinating health care.

Adult↗
PubMed2001

The costs of caring: medical costs of Alzheimer's disease and the managed care environment.

This review summarizes the medical costs associated with Alzheimer's disease (AD) and related dementias, as well as the payers responsible for these medical costs in the US health care system. It is clear from this review that AD and related dementias are associated with substantial medical costs. The payers responsible for a majority of these costs are families of patients with AD and the US government through the Medicare and Medicaid programs. In an attempt to control expenditures, Medicare and Medicaid have turned to managed care principles and managed care organizations. The increase in "managed" dementia care gives rise to several potential problems for patients with AD, along with many opportunities for systematic improvement in the quality of dementia care. Evidence-based disease management programs provide the greatest opportunities for improving managed dementia care but will require the development of dementia-specific quality of care measures to evaluate and continually improve them.

Alzheimer Disease↗
PubMed1995

CHAMPUS psychiatric inpatient savings: military management versus contractor, the Fort Polk experience.

Inpatient psychiatric costs were a significant part of the CHAMPUS bill at Bayne Jones Army Community Hospital. With implementation of Gateway to Care, a case management program was developed for intervention. In May 1993, Foundation Health Federal Services Inc. began a modified CHAMPUS Reform Initiative program providing an opportunity to retrospectively analyze two methods of managed care. Civilian hospital inpatient admissions for both programs during fiscal year (FY) 1993 were compared to corresponding periods in FY 1992. Under the case management program, admissions were reduced by 67%, occupied bed days by 74%, and costs by 76%. Under the Foundation Health Program, admissions were reduced by 13%, occupied bed days by 15%, and total costs by 42%. Both methods achieved savings over standard CHAMPUS. In spite of constraints that Foundation Health did not have, the case management program appeared to be more effective, demonstrating that a managed health care program directed by the hospital commander can significantly reduce costs.

Contract Services↗
PubMed2002

Characteristics of eye care practices with managed care contracts.

OBJECTIVES: To describe the variation in practice structure, financial arrangements, and utilization and quality management systems for eye care practices with managed care contracts. STUDY DESIGN: Cross-sectional survey of 88 group and 56 solo eye care practices that contract with 6 health plans affiliated with a national managed care organization. The survey contained modules on practice structure, financial arrangements, utilization management, and quality management. The survey response rate was 85%. RESULTS: Group practices with both ophthalmologists and optometrists were triple the size of ophthalmology-only groups, and 5 times the size of optometry-only groups. Fee-for-service payments were the primary source of group practice revenues, although 60% of groups derived some revenues from capitation payments. Group practices paid their physicians almost exclusively with fee-for-service payments or salary arrangements, with minimal capitation at the individual level. Almost no practices used both capitation and bonuses to compensate providers. Most practices received practice profiles and three fourths were subject to utilization review, which mainly consisted of preauthorization for procedures, tests, or referrals. Nearly all practices used clinical guidelines, protocols, or pathways in managing patients with diabetic retinopathy or glaucoma. Further, nearly all group practices used computerized information systems to assist in delivering care, and most had provider education programs. CONCLUSIONS: Managed care has affected the way eye care providers organize, finance, and deliver healthcare. In general, our findings paint an optimistic picture of eye care practices that contract with managed care organizations. Few practices bear substantial financial risk, and nearly all practices use quality management tools that could help to improve the quality of care.

Capitation Fee↗
PubMed1993

Practice management education--are residency programs properly preparing physicians for the 21st century?

Several surveys indicate that third-year physician residents and recent graduates felt that their training in practice management skills was inadequate and that they felt unprepared in this area. This professional paper will present a discussion of residency education and the current complex health care environment. It will also describe a three-year comprehensive curriculum in practice management which can be incorporated into the programs.

Curriculum↗