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Managed care now covers almost a quarter of all Medicaid participants, but only a handful of those receiving long term care. And no wonder: Where could the savings be found? A few model programs indicate how--and whether--Medicaid managed care for long term care can work.
In recent years, managed care organizations have permeated the medical marketplace in many large cities. Although the number of managed dental care programs has grown, it has been extremely difficult for experts to chart a course for managed dental care. At present, there are massive conflicts arising out of diverse philosophical, political and economic issues, which serve as barriers to the establishment of efficient and effectual dental delivery systems.
OBJECTIVE: To identify exemplary programs on midlife women's health issues that have been developed and implemented in managed care settings. METHODS: Members of The American Association of Health Plans (AAHP) were invited by mail to submit information on their exemplary programs on midlife women's health issues. AAHP and HealthPartners Research Foundation established 12 criteria by which to evaluate the programs submitted. Following telephone interviews with representatives of eligible programs, they were asked to complete an extensive survey about their successful practices. The Women's Health Task Force of AAHP then reviewed and evaluated every program submission and selected 4 model programs on midlife issues for women. RESULTS: The 4 model programs included the use of health assessment questionnaires to assist providers in identifying risk areas and patients' needs for information; group educational sessions focusing on midlife issues related to lifestyle and hormone replacement therapy; a module-based curriculum syllabus; and an osteoporosis disease management program. All groups utilize multidisciplinary teams to develop and promote educational programs. CONCLUSIONS: As study findings add to our knowledge of menopause treatment approaches and as new information and products become available, some managed care plans are using innovative channels of communication to keep women informed.
This evaluation of 24 hospital-based case management services found that case management could take a variety of forms, ranging from postacute medical management service to planning community-based care for potential long-term care users. Future research should concentrate on documenting the costs and outcomes of various models of case management in acute care settings.
Sources of financial uncertainty under capitation plans include not knowing the game rules, using the wrong game rules, basing financial decisions on incomplete data, or even being clueless about the factors that will determine financial risk. Financial risks under managed care can involve price, utilization, selection, and partner risks. Risks can vary by contract type. Controlling risk requires adequate information. Methods to manage risk include the modeling of risk implications; reliance on the law of large numbers; and the use of risk-sharing arrangements, stop-loss insurance, traditional insurance techniques, and various specific contracting techniques.
In the healthcare industry, the rules of regulation and competition often collide. Despite the view of Medicine as a "learned profession", it is clear that physicians will be subject to the same legal restrictions against sharing price information as those in place for any other industry. Thus, the relevant provisions of antitrust law will apply to most activities of physicians. Although recent case law has involved actions undertaken by physicians in other specialties of Medicine (e.g. oncology) the activities reviewed will likely be applicable to Dermatologists as well.
The method of health care financing and delivery has evolved over the last decade with managed care making a clinical and financial impact on otolaryngology practices. The trend is for third-party payers to shift the financial risk of delivering care to the physicians. Otolaryngologists must now be versed in reading and negotiating managed care contracts and be cognizant of the business processes in their practice. Otolaryngology practices of the 90s will have to demonstrate competence in their ability to standardize administrative processes and contain administrative costs.
Malpractice cases in which the defense was based on cost-containment are discussed in this article reprinted from Ophthalmic Risk Management Digest. These cases illustrate that the "dollar defense" is no defense.
No specialty better personifies the changes occurring throughout the health care delivery system than emergency medicine. It was just a short 25 years ago that the specialty of emergency medicine, as it is known today, emerged. The full-time staffing of EDs arose out of a need by patients who were presenting in ever-increasing numbers to hospital EDs that were staffed by a nurse or part-time physician. The specialty has continued to be responsive to the changing health care system throughout the past 25 years with innovations such as fast track units, observation units, and chest pain treatment center. To develop a vision for the future of the specialty, it is important to first evaluate the current trends in health care and their influences on the specialty. Three significant areas stand out in the current health care landscape: consolidation of hospital systems, emergence of publicly traded physician practice management companies, and the increasing penetration of managed care.
OBJECTIVE: To review how managed care is changing the traditional practice of pharmacy and the selection of pharmacy personnel. DATA SOURCES: Pharmacy practice journals and health care management journals were reviewed. Search terms included managed care, case management, pharmacists and Gallup Poll, drug use review, and patient compliance. STUDY SELECTION: References were used based on their relevance to describing managed care-driven changes in pharmacy and the potential threats and opportunities associated with these changes. DATA SYNTHESIS: The literature reviewed confirms that managed care is an increasing presence in the health care delivery system and that its influence is spreading to pharmacy. Health care practitioners, including pharmacists, are realigning and redefining their scope of practice to remain viable within the evolving system. CONCLUSION: As the drug delivery system changes, the expectations and roles of its practitioners are changing. The practice of pharmacy is changing from a distributive function to a cognitive one. This change will affect all pharmacy practice sites and will necessitate the hiring of pharmacists who are well qualified to deal with additional requirements. Failure to select qualified personnel may well exclude pharmacy from a major portion of the health care delivery system.
We describe the design of the Managing Anti-coagulation Services Trial (MAST), a practice-improvement trial testing whether anticoagulation services are a preferred method of managing anticoagulation for stroke prevention among patients with atrial fibrillation. Most randomized trials within the health care environment are designed as efficacy studies to determine what works under ideal conditions or ideal clinical practice. In contrast, effectiveness trials seek to generalize the results of efficacy studies by determining what works under more typical practice conditions. Practice-improvement trials are effectiveness trials that examine the management of a clinical problem in the context in which care is usually given. Noteworthy features of the MAST include defining the intervention in functional terms and collaboration with managed care organizations.
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At a recent meeting I attended in Bournemouth there was a lot of talk about 'managed care' in medicine and dentistry arriving in the UK. Managed care has already been introduced in the US and is the subject of many passionate debates. This article reviews managed care in the US and how it has affected health care over the last few years.
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This article examines the recent controversy in health care delivery about whether it should be conceptualized as a business. The current debate implicitly appeals to a common understanding of business and business practices that is no longer very useful. This common notion, which the authors call "cowboy capitalism," conceptualizes business as a competitive jungle resting on self-interest and an urge for competition in order to survive. The authors suggest that stakeholder capitalism offers a more useful framework for the dialogue about health care reform.
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