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At least 1,063 records · Page 59Linked to original sources
PubMed1988

Quality assurance of brokered services.

Case management programs that contract for client services act, in effect, as brokers of these services. Senior Care Network (SCN), a hospital-based, comprehensive, long term care program that includes a case management component, developed a quality assurance (QA) program to ensure the quality of its brokered services. At SCN, quality is controlled through a rigorous, systematic vendor selection process for service vendors and through vendor performance monitoring. Specific monitoring methods include incident reporting, quarterly meetings with vendors, client home visits, site visits to vendor offices, and annual vendor performance evaluations. Extensive external review requirements may eventually be added to the QA program to make it even more comprehensive.

Aged↗
PubMed1996

The role of adjunctive therapy in the management of chronic nonmalignant pain.

The management of chronic nonmalignant pain is an increasing challenge to clinicians and their patients. Adjunctive therapy, which includes a wide range of physical, psychoeducational, and multidisciplinary interventions, can play an important role in the treatment of pain. This article discusses the role and efficacy of adjunctive therapy in the management of pain associated with musculoskeletal conditions, the most common and disabling sources of chronic nonmalignant pain. Findings from meta-analyses, review articles, and recent clinical trials are reviewed that suggest that interventions that combine exercise and psychoeducational approaches designed to enhance communication, control, problem-solving, and coping can have a clinically significant impact on reducing pain and improving functional status for many conditions.

Chronic Disease↗
PubMed1999

Roadblocks to effective pain treatment.

Managed care "backlash" rhetoric to the contrary, roadblocks to effective pain treatment occur both intrinsic and extrinsic to the healthcare system. Pain medicine, an emerging, formally recognized specialty, and the special population of patients which it serves, experience additional discreet barriers. Chief among these is a lack of clear identity and recognition of the specialty and the disenfranchisement of many of the patients it serves in the American healthcare system. Special problems within various healthcare financing environments is discussed.

Government↗
PubMed1993

Internal and external forces affecting management compensation.

Increasing media scrutiny, eventual implementation of health care reform, and proliferation of TQM/CQI programs are significantly affecting health care management compensation programs. Trustees are insisting that management pay be based on definitive performance standards and are becoming increasingly resistant to the annual increase that is no longer sacrosanct. Philosophical conflicts regarding compensation are developing between CEOs and boards. These external and internal factors will require managers to reassess their attitudes toward their own and subordinate's compensation. Managers, at all levels, will have to adjust to pay determination factors and practices that differ from those to which they have been accustomed.

Budgets↗
PubMed1996

Managed care under siege: how an effective compliance program can protect your company.

This article discusses the current enforcement emphasis on managed care fraud and examines how managed care organizations can utilize compliance programs, including legal audits, to protect against unwarranted investigations and liability. The article reviews the elements of an effective compliance program, how to conduct an internal audit, and the risks and benefits of a voluntary disclosure in the event fraudulent activity is discovered.

Employee Performance Appraisal↗
PubMed2000

Medicaid managed care reimbursement for HIV and its implications for access to care.

The rapid growth of managed care in state Medicaid programs has raised concerns about access to care for people living with HIV and AIDS (PLWH). Even the highest capitation rates that most programs pay to managed care organizations (MCOs) for disabled enrollees are substantially lower than the costs of care, especially when costly protease inhibitor therapy is taken into account. A national study has shown that Medicaid beneficiaries did not have the same level of access to protease inhibitors as did privately insured HIV patients in 1996 and 1997. Low capitation rates can limit access to care for PLWH by discouraging MCOs from having experienced HIV physicians on their provider panels and from enrolling PLWH. Since 1997, however, Medicaid programs in several states have adopted strategies to reduce the financial risks facing MCOs caring for PLWH and enrollees with other high-cost conditions. These strategies include global health-based (risk-adjusted) payment systems, AIDS-specific reimbursement rates, carve outs from capitation rates for medications and other services, risk pools for high-cost enrollees, risk corridors, and stop-loss insurance policies through which Medicaid programs share financial liability with MCOs for catastrophic losses. In addition, several programs have developed HIV centers of excellence. Most state Medicaid programs have yet to adopt any of these strategies. However, the growing numbers and types of experimental approaches to capitating services for PLWH may provide models for other states whose low reimbursement rates currently limit access to care.

Capitation Fee↗
PubMed1998

Managing risks in managed care environment.

The healthcare environment is rapidly changing as managed care penetrates your community. Risk management in the office setting is becoming more critical as the strategies for preventing claims in the first place become more important. It is time to reexamine the environment that is being created, increase the involvement of patients in their own care, create documentation systems and recognize when you are at risk.

Documentation↗
PubMed2000

"Second-generation" Medicaid managed care: can it deliver?

This article offers insight into what we term "second-generation" Medicaid managed care. In case studies of seven States, we examined three critical questions: (1) Does managed care experience facilitate program operations? (2) Can Medicaid managed care deliver on important goals? and (3) Can States extend the program beyond low-income families and children to others? The answers are encouraging but also suggest caution. Medicaid managed care is not a solution to fundamental problems facing the Medicaid program. It may be a tool to encourage better delivery of care. This requires a long-term commitment and adequate financing to develop stable partnerships with all stakeholders.

Aged↗
PubMed1998

Managed care may crunch GME programs.

Can teaching hospitals continue operating graduate medical education programs in a world of cost-conscious purchasers, competitive marketplaces, and cutbacks in Medicare's financial support? The absence of widely evident financial problems may slow efforts to establish national trust funds for graduate medical education.

Cost Control↗
PubMed2001

Consistency of care with national guidelines for children with asthma in managed care.

OBJECTIVE: To evaluate the consistency of pediatric asthma care with the National Asthma Education and Prevention Program Guidelines. DESIGN: Cross-sectional survey at 2 managed care organizations in the United States (winter 1997-1998). The participants were parents of children (n = 318) age 5 to 17 years with asthma. There were no interventions. The outcome measures were indicators of care in 4 domains: (1) periodic physiologic assessment, (2) proper use of medications, (3) patient education, and (4) control of factors contributing to asthma severity. RESULTS: Of 533 eligible patients with asthma, 318 (60%) parents responded; 59% of children were male, 76% were white, and 60% were aged 5 to 10 years. Deficiencies in care were identified in all care domains including, for patients with moderate and severe persistent symptoms, only 55% used long-term control medication daily, 49% had written instructions for handling asthma attacks, 44% had instructions for adjustment of medication before exposures, 56% had undergone allergy testing, and 54% had undergone pulmonary function testing. CONCLUSIONS: There are significant opportunities to improve the quality of care for children with asthma enrolled in managed care. A comprehensive approach to improving care may be necessary to address multiple aspects of care where opportunities exist.

Adolescent↗
PubMed1996

Effects of global competition on health care administration in Finland and the United States. What you can do to save your practice.

Global competition, a faltering Finnish economy, and deep recession are forcing difficult decisions on the health care administrators of this Nordic country known for its extensive social welfare safety net and socialized health care system. In the first part of this article the Finnish health care system and its problems, as well as possible solutions, are presented. Similarities to our own system are noted and discussed. In an interview, the director general for the Minister of Social Affairs and Health of Finland, Kimmo Leppo, expressed concern about future funding sources in his country for the same levels of social welfare and health care programs that presently exist. The Finns are considering managed competition among providers, increasing copayments, excess hospital beds, anticipated hospital closures in their country, block grants, and how to deal with rising physician unemployment. He was interested in the proposed US government health care plans, and especially the state of Tennessee's TennCare plan, a state plan that closely resembled the failed Clinton health care reform package. The second part of this article explores how global competition has brought the pressure of modern competitive economics into the US medical arena.

Cost Savings↗
PubMed1992

Ethnic differences in emergency psychiatric care and hospitalization in a program for the severely mentally ill.

Ethnic differences in rehospitalization were examined in a program of intensive services for severely mentally ill hospital recidivists. The purpose was to determine whether ethnicity-related differences in psychiatric admissions observed in national data would appear among clients at great risk for hospitalization but enrolled in a program of case-managed care to promote community adjustment and tenure. After accounting for differences in prior emergency visits and hospitalizations as well as sociodemographic and clinical differences, blacks were found more likely than whites to visit the psychiatric emergency room and to be hospitalized. The marked needs of the severely mentally ill and the intention to address these needs with services did not obviate the continuing importance of racial differences in explaining reliance on inpatient sources of care.

Alcoholism↗