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This article presents a hypothetical fact pattern, in which preapproval for endoscopic retrograde cholangiopancreatography is denied by a managed care plan, to address the issues concerning potential liability for this decision. I described several risk management strategies for this situation designed to reduce the risk of a successful suit against a physician.
OBJECTIVE: To determine the extent to which managed care has led to consolidation among hospitals and physicians. DATA SOURCES: We use data from the American Hospital Association, American Medical Association, and government censuses. STUDY DESIGN: Two stage least squares regression analysis examines how cross-section variation in managed care penetration affects provider consolidation, while controlling for the endogeneity of managed-care penetration. Specifically, we examine inpatient hospital markets and physician practice size in large metropolitan areas. DATA COLLECTION METHODS: All data are from secondary sources, merged at the level of the Primary Metropolitan Statistical Area. PRINCIPAL FINDINGS: We find that higher levels of local managed-care penetration are associated with substantial increases in consolidation in hospital and physician markets. In the average market (managed-care penetration equaled 34 percent in 1994), managed care was associated with an increase in the Herfindahl of .054 between 1981 and 1994, moving from .096 in 1981 to .154. This is equivalent to moving from 10.4 equal-size hospitals to 6.5 equal-sized hospitals. In the physician market place, we estimate that at the mean, managed care resulted in a 14 percentage point decrease of physicians in solo practice between 1986 and 1995. This implies a decrease in the percentage of doctors in solo practice from 38 percent in 1986 to 24 percent by 1995.
OBJECTIVE: To examine how health plans have changed their approaches for managing costs and utilization in the wake of the recent backlash against managed care. DATA SOURCES/STUDY SETTING: Semistructured interviews with health plan executives, employers, providers, and other health care decision makers in 12 metropolitan areas that were randomly selected to be nationally representative of communities with more than 200,000 residents. Longitudinal data were collected as part of the Community Tracking Study during three rounds of site visits in 1996-1997, 1998-1999, and 2000-2001. STUDY DESIGN: Interviews probed about changes in the design and operation of health insurance products--including provider contracting and network development, benefit packages, and utilization management processes--and about the rationale and perceived impact of these changes. DATA COLLECTION/EXTRACTION METHODS: Data from more than 850 interviews were coded, extracted, and analyzed using computerized text analysis software. PRINCIPAL FINDINGS: Health plans have begun to scale back or abandon their use of selected managed care tools in most communities, with selective contracting and risk contracting practices fading most rapidly and completely. In turn, plans increasingly have sought cost savings by shifting costs to consumers. Some plans have begun to experiment with new provider networks, payment systems, and referral practices designed to lower costs and improve service delivery. CONCLUSIONS: These changes promise to lighten administrative and financial burdens for physicians and hospitals, but they also threaten to increase consumers' financial burdens.
Dermatologists in the US have had many years experience in dealing with managed care and some lessons for survival and even thriving have become clear. First is to try to prevent managed care. By pointing out its history of failure in many countries it is still possible to prevent the catastrophe, to patient, physician and final payer, that managed care does represent. If prevention is not possible, minimizing its impact by promoting direct access, unbundling, and wider coverage is important. In addition, dermatologists will need to maximize reasonable sources of direct pay alternatives.
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Research on pharmacy benefit management companies focuses on descriptive accounts of the organizations and the scope of their services. This review provides a critical analysis of publicly available research on contemporary issues surrounding the operations and effects of pharmacy benefit management companies. There has been very little systematic, empirical research on these issues; major questions concerning the impact of pharmacy benefit management companies on quality, costs, and patient outcomes remain unanswered. We analyze what is known and what needs to be known, and we explore major research challenges that lie ahead in the assessment of the pharmacy benefit management company's role in the health care system and in improving the public's health.
Drawing on a nationally representative survey of physicians, this paper examines the extent to which physicians split their time between primary care and non-primary care activities and whether managed care makes a difference. We find that managed care does matter: Physicians have been narrowing their scope of practice, and the trend is linked to their involvement with managed care plans. These findings have implications for workforce policy and training, regulation of managed care contracting, and the quality of care.
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This article is the second in a series of three compiling the results of the 1995 Managed Care Marketplace Information Survey conducted by the ADA Council on Dental Practice. This article addresses dentists' opinions on various statements regarding managed care. Most dentists had similar opinions regardless of whether they participated in managed care.
BACKGROUND AND OVERVIEW: The author examined the impact of trends in commercial insurance plans and their managed care products on the traditional fee-for-service solo or partnership model of dental practice. CONCLUSION: In response to rising dental expenditures, employers are passing on more costs of dental insurance to employees, dropping dental benefits altogether and moving from indemnity to managed care plans, mainly preferred provider organizations. These trends are likely to continue, resulting in fewer people with employer-based dental insurance coverage. PRACTICE IMPLICATIONS: These changes in dental insurance coverage are unlikely to challenge the traditional model of dental practice within the next five years, largely because of the growing decline in the supply of dental services and a lack of local market concentration of dental managed care companies.
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BACKGROUND: In the past three decades, dental insurance has become a permanent fixture in the delivery of dental services. Some would argue that this has not been good for dentists. However, none will dispute that it is here to stay and that dentists must make some very important decisions in their practices with regard to dental insurance. This article will explore some of those decisions and offer some guidance on how to decide wisely. CONCLUSIONS: Dental insurance now is a permanent fixture in the delivery of dental care. Each dentist must decide if participation with a dental insurance company is in his or her best interest. To make this decision, a dentist must have as much information as possible to evaluate each specific dental plan. If a dentist does decide to participate, the dentist must know the rules. PRACTICE IMPLICATIONS: Participation with a dental insurance company may influence the dentist-patient relationship. Dentists must be prepared to answer the question, "Why do I need this service if my dental insurance does not cover it?" Non-participation with a dental insurance company may result in a reduced number of new patients.
Few issues are more central to the ongoing debate about health care in the United States than concerns about cost and quality of medical care. The recent development and implementation of medical management guidelines that include recommendations for diagnostic and therapeutic interventions, hospital length of stay, intensity of service, home care, and access to specialists have often focused this debate on the potential trade-off between cost reductions and quality of care. The American Academy of Pediatrics recognizes that cost and quality are integrally related and that it is possible to reduce costs while maintaining and improving quality. The purpose of this statement is to help pediatricians and other health care providers interpret, evaluate, and improve medical management guidelines.
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