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PubMed2000

High-risk population health management--achieving improved patient outcomes and near-term financial results.

OBJECTIVE: A managed care organization sought to achieve efficiencies in care delivery and cost savings by anticipating and better caring for its frail and least stable members. STUDY DESIGN: Time sequence case study of program intervention across an entire managed care population in its first year compared with the prior baseline year. PATIENTS AND METHODS: Key attributes of the intervention included predictive registries of at-risk members based on existing data, relentless focus on the high-risk group, an integrated clinical and psychosocial approach to assessments and are planning, a reengineered care management process, secured Internet applications enabling rapid implementation and broad connectivity, and population-based outcomes metrics derived from widely used measures of resource utilization and functional status. RESULTS: Concentrating on the highest-risk group, which averaged just 1.1% prevalence in the total membership, yielded bottom line results. When the year before program implementation (July 1997 through June 1998) was compared with the subsequent year, the total population's annualized commercial admission rate was reduced 5.3%, and seniors' was reduced 3.0%. A claims-paid analysis exclusively of the highest-risk group revealed that their efficiencies and savings overwhelmingly contributed to the membershipwide effect. This subgroup's costs dropped 35.7% from preprogram levels of $2590 per member per month (excluding pharmaceuticals). During the same time, patient-derived cross-sectional functional status rose 12.5%. CONCLUSIONS: A sharply focused, Internet-deployed case management strategy achieved economic and functional status results on a population basis and produced systemwide savings in its first year of implementation.

Algorithms↗
PubMed1996

Promoting use of a preferred histamine H2-receptor antagonist in managed care organizations.

A program to promote generic cimetidine as the preferred histamine H2-receptor antagonist (HRA) in the managed care organizations (MCOs) served by a pharmacy benefit management company is described. A pharmacy benefit management company conducted a literature review to substantiate the therapeutic equivalence of the HRAs and to set conservative criteria for identifying candidates for conversion to oral cimetidine therapy. During the third quarter of 1994, the prescriber for each patient identified was sent a document listing the patient's current HRA therapy, the date of his or her last prescription refill, and the name and telephone number of the dispensing pharmacy. A letter summarized the literature; outlined the criteria used to identify candidate patients; gave the current indications, dosages, and average wholesale prices of the HRAs; and asked the prescriber to switch the patient to generic cimetidine. HRA use in an MCO that participated in the program was compared with HRA use in a nonparticipating MCO for the second quarter of 1994 (the baseline period), the fourth quarter of 1994, and the first quarter of 1995. The nonparticipating MCO showed no change between baseline and 1995 in the proportion of HRA prescriptions accounted for by brand-name and generic cimetidine combined (14% for each period). The average acquisition cost per HRA prescription remained about $75 for each study quarter. In the participating MCO, the proportion of HRA prescriptions accounted for by brand-name plus generic cimetidine increased from 18% at baseline to 39% in the first quarter of 1995. The average acquisition cost per HRA prescription fell from $71 at baseline to $65 in the first quarter of 1995. A program to shift the use of brand-name HRAs to generic cimetidine in MCOs successfully altered prescribing patterns and reduced expenditures for these agents.

Cimetidine↗
PubMed2000

Ethics versus commercialism in the professions.

Over the last two decades forces have been at work which have changed the ethic of many of the professions. This paper examines the nature of these forces, the evidence of the changes and possible ways of retaining our professionalism.

Advertising↗
PubMedDate not supplied

Baby love and budget relief: some promising practices in prenatal managed care in Medicaid.

The provision of prenatal health care is one of the most important functions of Medicaid, as approximately three-quarters of program enrollees are poor women and children. A rapidly increasing number of states are seeking to address the dual crises of spiralling program costs and inadequate access to services through the use of managed care in Medicaid. Medicaid managed care is growing rapidly and now stands at more than 8 million enrollees, the overwhelming majority of whom are women and children. The focus on accessible preventive and primary care that is, in theory, the hallmark of managed care, should apply well to prenatal health services for Medicaid beneficiaries, though this is not always the case. The more successful managed prenatal care programs thus far have some common characteristics, which are examined here in the hope that they will be replicated by other states.

Centers for Medicare and Medicaid Services, U.S.↗
PubMed2003

Employer satisfaction with workers' compensation health care: results of the Washington State Workers' Compensation Managed Care Pilot.

Developing more effective approaches to disability prevention has been a longstanding challenge for the workers' compensation system. A major obstacle to this goal has been the lack of communication and interaction between employers and physicians who care for injured workers. From 1995 through 1997, the Washington State Department of Labor and Industries sponsored a major demonstration program, known as the managed care pilot (MCP), to assess the effects of managed care on medical and disability costs, patient satisfaction and employer satisfaction. We developed a telephone survey and administered it to 243 employers as part of the MCP evaluation. Topics covered in this survey include satisfaction with treatment rendered, duration of lost work time, work modifications, and satisfaction with communication received during the employee's recovery period. Employers in the intervention (managed care) condition were more satisfied with the managed care/occupational medicine system than the employers in the comparison group were with the fee-for-service system. MCP employers were satisfied particularly with the frequency and quality of communication received from the health care provider regarding return to work and work modification issues. Improved employer-provider communication may foster early return to work and thereby have a beneficial effect on health and employment outcomes for injured workers.

Fee-for-Service Plans↗
PubMed1997

Intermediate care programs to reduce risk and better manage inmates with psychiatric disorders.

Intermediate Care Programs were jointly established by the New York State Office of Mental Health and Department of Correctional Services to reduce risk and better manage inmates with psychiatric disorders. In an earlier study, we collected data from the mental health and corrections records of 209 inmates who were admitted to Intermediate Care Programs. Our analysis of those data showed there were significant reductions in the mean number of serious problem behaviors, correctional restrictions, and mental health crisis services during the six months before and after admission. In the present study, we used Wilcoxon tests to assess changes in the distribution of scores on variables assessed by the earlier study. The Wilcoxon tests showed there were significant changes in the distribution of scores on most of the variables. We then focused on inmates who scored positive on the respective variables, either before admission or after admission, and determined the percentage who improved, stayed the same, or worsened on those variables. The highest reductions occurred in mental health observations (65%), suicide attempts (63%), and emergency medications (43%). Lower reductions occurred in correctional infractions and restrictions (26% to 31%). Overall, the data from this study and our earlier one suggest that Intermediate Care Programs are effective in reducing risk and managing inmates with psychiatric disorders.

Adult↗
PubMed1998

Earlier discharge of infants from neonatal intensive care units: a pilot program of specialized case management and home care. Delaware Valley Child Health Alliance.

A multidisciplinary approach using a neonatology independent physicians association, affiliated hospitals, a pediatric home care company, and a health maintenance organization was designed to promote earlier safe discharge of infants from intensive care. This pilot project involved 43 infants who received case management and early discharge home with home oxygen, monitoring, intravenous antibiotics, gavage feedings, phototherapy, or nutritional management for poor weight gain. A staff neonatologist remained the primary physician until the patient would have been discharged according to standard criteria. Two patients had unscheduled readmissions and all infants survived. This approach resulted in an estimated savings of 456 hospital days and $329,982; 89% of parents rated the care as good to excellent, and 83% were satisfied with the program and outcome. This study suggests that a prospectively designed program can be designed to promote safe earlier discharge of infants in intensive care.

Case Management↗
PubMed1995

Service utilization and costs of care for severely mentally ill clients in an intensive case management program.

OBJECTIVE: The study evaluated the effects of an intensive case management model on clients' use of inpatient and outpatient psychiatric care and on the costs of care. METHODS: Ninety clients of a county mental health system who were frequent users of inpatient services were randomly assigned to either an intensive case management group, a traditional case management group, or a control group who received no particular services. Outcome variables measured over a two-year period were number of units used by clients and costs of inpatient care in county and private facilities and various types of outpatient care, including day treatment and use of an emergency psychiatric unit. RESULTS: Clients who received intensive case management had fewer inpatient days and reduced overall costs for mental health services. CONCLUSIONS: Assertive outreach and intensive case management can reduce hospitalizations of clients who are frequent users of inpatient care and can reduce overall mental health care costs. Mental health consumers employed as case management aides can play an important role in the delivery of mental health services, particularly with frequent users of inpatient care.

Adolescent↗
PubMed1996

Strategic options in capital budgeting and program selection under fee-for-service and managed care.

Many assets and projects provide value to organizations in excess of the direct and indirect cash flows that they generate. Under pure capitation, the link between individual investment decisions and future cash flows is completely severed. Including the value of strategic options enhances the usefulness of the capital budgeting process for health care organizations and provides a means of adapting that process to managed care settings.

Budgets↗
PubMed1997

Fee-for-service dentistry or managed care: one dentist's opinion.

Contrasts are drawn between dental care based on fee-for-service and managed care financial arrangements. The advantages of fee-for-service include (for the profession) slow acceptance of managed care in dentistry compared to medicine; (for society and the patient) more community service, higher technical quality of work, and stimulation of innovations; and (for the individual dentist) the strong dentist-patient bond as well as professionalism.

Attitude of Health Personnel↗
PubMedDate not supplied

Case management in a wound care program.

Patients who need wound care can present a complex challenge in the current managed care environment. Managing health care benefits and financial and socioeconomic factors that impact wound healing are as crucial to wound healing as providing aggressive wound care. Case management is used to describe the strategies involved in coordinating patient care to achieve optimal clinical and financial outcomes and ensure quality and continuity of care. In this article, the author illustrates how case management plays an integral part in a wound care program. The article features tips on how to effectively use limited financial resources that burden many patients who need wound care, includes ways to approach physicians when current wound care is not effective, and focuses on early discharge planning and a multidisciplinary team approach to ensure optimal clinical and financial outcomes. To help sharpen skills, included at the end of the article is a Case Study Challenge and tools to use in practice: Case Management Plans for Wound Patients.

Adult↗
PubMedDate not supplied

Immunization coverage and Medicaid managed care in New Mexico: a multimethod assessment.

BACKGROUND: We wanted to examine the association between Medicaid managed care (MMC) and changing immunization coverage in New Mexico, a predominantly rural, poor, and multiethnic state. METHODS: As part of a multimethod assessment of MMC, we studied trends in quantitative data from the National Immunization Survey (NIS) using temporal plots, Fisher's exact test, and the Cochran-Armitage trend test. To help explain changes in immunization rates in relation to MMC, we analyzed qualitative data gathered through ethnographic observations at safety net institutions: income support (welfare) offices, community health centers, hospital emergency departments, private physicians' offices, mental health institutions, managed care organizations, and agencies of state government. RESULTS: Immunization coverage decreased significantly after implementation of MMC, from 80% in 1996 to 73% in 2001 for the 4:3:1 vaccination series (Fisher's exact test, P = .031). New Mexico dropped in rank among states from 30th for this vaccination series in 1996 to 50th in 2001. A significant decreasing trend (Cochran-Armitage P = .025) in coverage occurred between 1996 and 2001. Findings from the ethnographic study revealed conditions that might have contributed to decreased immunization coverage: (1) reduced funding for immunizations at public health clinics, and difficulties in gaining access to MMC providers; (2) informal referrals from managed care organizations and contracting physicians to community health centers and state-run public health clinics; and (3) increased workloads and delays at community health centers, linked partly to these informal referrals for immunizations. CONCLUSIONS: Medicaid reform in New Mexico did not improve immunization coverage, which declined significantly to among the lowest in the nation. Reduced funding for public health clinics and informal referrals may have contributed to this decline. These observations show how unanticipated and adverse consequences can result from policy interventions in complex insurance systems.

Anthropology, Cultural↗
PubMedDate not supplied

Redesigning case management in managed care: an eclectic approach: from city to ranch.

Case management programs are a common approach to managing the quality and cost of services in managed care organizations. Once developed these programs may grow stagnate as the managed care member population grows and changes. This article presents a redesign project initiated by a managed care organization located in a rural Southwest region of the United States. Nursing theory and case management standards of practice form the basis of the redesign project and will be discussed. The case management model, including roles and responsibilities of staff, are presented. Results and future implications are identified.

Case Management↗
PubMed2001

Care for children with special health care needs in a managed care system: a patient satisfaction survey.

In 1994 the government of Puerto Rico adopted a capitated managed health care system for the medically indigent. The new law has been implemented in most municipalities. A survey of children with special health care needs treated at a tertiary pediatric center under the capitated managed care system and the prior non-capitated system was analyzed using the Consumer Assessments of Health Plan Survey (CHAPS) instrument. One third of the patients who were under the new capitated managed care system were not satisfied with the medial care they were receiving. The parents of children with multidisciplinary conditions found it much more difficult to access care at the tertiary center. It took parents two years to learn to navigate within the capitated managed care system. Studies to measure outcome and health quality of children with special health care needs in capitated managed health care programs must be developed to learn how the potential benefits of managed care can be maximized and the potential harms minimized. The purpose of this study was to analyze the accessibility and satisfaction of caretakers of children with special health care needs under a capitated managed health care system.

Adolescent↗