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PubMedDate not supplied

Tracking Medicaid managed care in rural communities: a fifty-state follow-up.

This study updates a 1997 study examining implementation of rural Medicaid managed care programs. Most states operate Medicaid managed care programs for their beneficiaries, but the types of programs vary across urban and rural settings. Over the past four years the number of rural counties covered by Medicaid managed care, including fully capitated programs, has grown, although primary care case management (PCCM) remains the predominant program type in rural areas. Health plan withdrawals from rural areas have led some states with rural capitated programs to provide financial incentives or develop alternative approaches, such as enhanced PCCM programs.

Budgets↗
PubMed2004

Assessing the need for a clinical COPD care program in a managed care organization.

BACKGROUND: Chronic obstructive pulmonary disease (COPD), a systemic inflammatory condition, is costly and often devastating to patient quality of life. COPD is also greatly underdiagnosed and often inappropriately treated. A managed care organization therefore evaluated whether a systemwide COPD clinical program within its organization may be appropriate. The organization examined the current prevalence, costs, and adherence to clinical treatment guidelines. OBJECTIVE: To identify the prevalence and costs of COPD within the managed care organization and to ascertain whether the condition could be better managed using a systemwide clinical program. CONCLUSION: Both diagnosis and treatment of COPD would likely be improved with a comprehensive clinical COPD care program that would include measuring outcomes, stratifying COPD patients by risk, and initiating disease state management efforts.

Disease Management↗
PubMed1998

The role of nutrition screening and intervention programs in managed care.

Nutrition screening and intervention programs provide managed care plans with an opportunity to meet the needs of the increasing Medicare risk population. Recently, representatives from various health plans came together to discuss program benefits as well as the best practices in the development and implementation of such programs to ensure successful outcomes. Through simple and cost-effective programs, health plans can improve member satisfaction, resource utilization, and the health status of their members.

Aged↗
PubMed1999

Managed care of children with special health care needs: the ABC Program.

Families of children voluntarily enrolled in a managed care program for children with special health care needs receiving SSI and Medicaid benefits and their case managers were surveyed regarding care satisfaction, quality, and access. Claims data were used to compare the cost and utilization of health care before and during program enrollment. Families rated health care quality improved in 43%, unchanged as "excellent" in 50% of cases. The care received was seen as more nearly complete and of higher quality when the provider was based in the hospital or the hospital's community clinics as compared with "private" community pediatricians. Hospitalization decreased, but no decrease in cost was demonstrated. A carefully planned and implemented managed care program can improve patient perception of quality among chronically ill children.

Child↗
PubMed2000

Medicaid and indigent care issue brief: Medicaid: managed care.

In an effort to reduce the high cost of fee-for-service health care, many states have implemented managed care into their Medicaid programs. Managed care has many forms, but the most traditional measures states adopt are fully capitated, partially capitated, or primary care case management (PCCM) programs. According to the Kaiser Commission on the Future of Medicaid, enrollment in Medicaid managed care has grown dramatically from 2.7 million beneficiaries in 1991 to 16.6 million in 1998. Over half (53.6 percent) of Medicaid beneficiaries, predominately poor children and their parents, are enrolled in some form of managed care.

Humans↗
PubMed1996

Diabetes and managed care: the Lovelace Health System's Episode of Care Program.

In order to efficiently manage the care of large populations, the health of that population must be evaluated. People identified with chronic medical disorders, such as diabetes mellitus, should have their disease managed proactively in the most cost-effective manner across the continuum of care. Lovelace Health System has established an Episode of Care disease management program based on the principles of clinical practice improvement. The diabetes program is described as an example of this approach to define and monitor best practice and to decrease variation among providers. This approach optimizes the use of health care resources and improves patient outcomes.

Continuity of Patient Care↗
PubMed1998

Clinical and economic impact of implementing a comprehensive diabetes management program in managed care.

Diabetes mellitus places a significant burden on the U.S. healthcare system. Because of the potential to reduce diabetic complications and costs through intensive management, diabetes has become a primary target for disease management programs. We performed a retrospective analysis of short-term baseline and follow-up clinical, economic, and member and provider satisfaction data from approximately 7,000 people with diabetes being treated through seven managed care plans using Diabetes Treatment Centers of America's Diabetes NetCare, (Nashville, TN), a comprehensive diabetes management program. Our analysis indicates that Diabetes NetCare achieved gross economic adjusted savings of $50 per diabetic member per month (12.3%), with gross unadjusted savings of $44 (10.9%) per diabetic member per month. Hospital admissions per 1,000 diabetic member years decreased by 18%, and bed days fell by 21%. Patients with diabetes were more likely to get HbAlc tests, foot exams, eye exams, and cholesterol screenings while enrolled in the program. These data suggest that implementation of a comprehensive healthcare management program for people with diabetes can lead to substantial improvements in costs and clinical outcomes in the short-term. It is expected that improvements will increase over time, with continuing improvements in health status and a reduction in the number of future diabetic complications.

Adult↗
PubMed2000

Health plan responses to Medicaid managed care policy in New York City.

Nearly all states in the United States have instituted managed care programs to serve Medicaid recipients and are developing policies to increase program participation. State practices regarding managed care contracting, premiums, and enrollment have implications for whether managed care plans will respond in a manner consistent with overall state policy objectives for the Medicaid managed care program. The experience of expanding the Medicaid managed care program in New York City, where the number of Medicaid beneficiaries exceeds the number in all but three states, has provided an interesting opportunity to look at the relationship between Medicaid managed care policy and plan enrollment. This paper analyzes trends in Medicaid managed care enrollment in New York City from January 1991 to September 1998, a period of critical changes in Medicaid managed care policy in New York.

Attitude of Health Personnel↗
PubMed2004

Family reports of care denials for children enrolled in TennCare.

OBJECTIVE: Twenty-three million people, accounting for >58% of Medicaid enrollees, are enrolled in Medicaid managed care programs. Although the expectation of management in Medicaid managed care programs necessitates restrictions in use of some services sought by patients and families, the circumstances surrounding care denial and related access problems in vulnerable populations of children have not been studied. The objective of this study was to identify experiences with care denial reported by families in TennCare, Tennessee's managed care program for Medicaid enrollees and uninsured. METHODS: Primary caregivers for 399 children who were enrolled in TennCare and presented for care at 21 pediatric and family medicine sites throughout Tennessee participated in a face-to-face interview. RESULTS: Of the 399 caregivers who participated in the study, 146 (36.6%) reported that their child experienced denial of care in the previous 12 months at a physician's office (12.5% of those interviewed), dentist's office (13.8%), or pharmacy (20.0%). For denial of any 1 type of care, families of children with chronic conditions (multivariable odds ratio [OR]: 2.05; 95% confidence interval [CI]: 1.41-2.99) and those whose parents had >12 years of education (OR: 1.80; CI: 1.21-2.70) were more likely to report denial of care; families of black children were less likely to report denial than white children (OR: 0.34; CI: 0.20-0.56). Content analysis of caregiver perceptions identified provider concerns about reimbursement as a factor in denials. Of the children who could not be seen by a physician, caregivers perceived that 12.2% became sicker as a result of the delay in care; 16.3% reported an emergency department visit after the denial. CONCLUSIONS: More than one third of TennCare families reported denials of care for their children in the previous year, and factors surrounding these denials were identified. Given the large number of Americans who receive health care through Medicaid managed care programs like TennCare, more research is needed to understand the implications of denied care for children and families who are enrolled in these programs.

Adolescent↗
PubMed2000

Managed care for the Medicaid disabled: effect on utilization and costs.

The objective of this study was to describe the effect on health care utilization and costs of a program of managed care for the Medicaid disabled. The study was designed as a pre/post enrollment cohort comparison and was carried out in three Ohio counties. The subjects were disabled Medicaid-insured patients who voluntarily enrolled in a managed care program for at least 6 months between July 1, 1995 and December 31, 1997, and who had (1) at least one Medicaid claim in the 24-months pre-enrollment period and (2) overall satisfactory postenrollment encounter-level data. Ohio Medicaid provided claims and reimbursements (costs) for the pre-enrollment period and encounter-level data for the postenrollment period. Postenrollment costs were estimated by applying category-specific average pre-enrollment costs to postenrollment utilization data. We measured the following per patient-month: (1) trends in category-specific utilization and costs for up to 24 months before and after enrollment, (2) differences in overall and category-specific costs 1 year before and after enrollment, and (3) changes in the distribution of services 1 year before and after enrollment. Utilization categories included inpatient care, outpatient hospital (including emergency department) care, physician services, prescription medications, durable medical equipment and supplies, and home health care. We found that satisfactory encounter data were available in two of three counties. Of 1,179 enrollees, 592 met all inclusion criteria. Before enrollment, utilization and costs were increasing significantly in four of six categories and were unchanging in two. Postenrollment, decreasing utilization was observed for three categories, one remained unchanged, and two were increasing, but from a lower "baseline." Except for physician services and home health care, there were lower utilization and estimated costs in all categories in the year after enrollment. Estimated inpatient and total costs declined by $155/patient-month (44.9%) and $210/patient-month (37.1%), respectively. Findings were similar across sites. Inpatient care, outpatient hospital care, and prescription medications accounted for 97% of the reductions in estimated costs in the postenrollment period. Among patients voluntarily enrolled for at least 6 months, managed care for the Medicaid disabled was associated with striking decreases in health care utilization and estimated costs. The effect of managed care on these patients' satisfaction, access to specialized services, quality of care, and health outcomes are understood incompletely.

Case Management↗
PubMed1988

An evaluation of Utah's primary care case management program for Medicaid recipients.

One of the first case management (CM) programs for limiting Medicaid enrollees' freedom of choice of provider was established by Utah. By assigning enrollees to specific providers responsible for arranging all nonemergency care, Utah intended both to improve access and to reduce program costs. State officials expected the program to increase recipients' use of primary-care providers, while reducing their use of specialists, prescription drugs, and hospital outpatient services. Savings from reductions in unnecessary use were expected to more than offset increases in outlays arising from access enhancements, resulting in lower program expenditures. This study investigated the extent to which the state Medicaid program achieved these goals. The analysis was based on a two-part multivariate model of usage, estimated from data created from claims-level information provided by Utah. The findings revealed that the use of primary-care physician services increased significantly. However, the program also raised the use of specialists' services and prescription drugs. In contrast, the use of hospital outpatient services was lowered. Overall, CM apparently achieved the objective of increased access, but failed to attain the cost-containment goal. The findings indicated that expected costs for ambulatory care rose by 25% in the early years as a result of case management.

Cost Control↗
PubMed2001

Effects of managed care on programs and practices for the treatment of alcohol and drug dependence.

Managed care is affecting the organization and financing of treatment services for alcohol and drug dependence. This paper examines the effects of managed care on program operations including the use of clinical protocols, the administrative burden, information systems, staffing, and program consolidation. It also reviews the effects of managed care on system performance related to employer-sponsored health plans, state employee health plans, and Medicaid and other public plans. Our review of managed care's influences on the alcohol and drug abuse treatment system finds evidence of systemic reductions in access to inpatient care and increased reliance on outpatient services. Moreover, although analyses of behavioral health carve-outs often suggest increases in the use of outpatient care, evaluations of substance abuse claims report reductions in ambulatory utilization for the treatment of alcohol and drug dependence.

Alcoholism↗
PubMed1996

Missed appointments and Medicaid managed care.

OBJECTIVES: To compare the demographic characteristics of patients who miss appointments with those who do not and to identify subgroups who would benefit from specific interventions for improving attendance. DESIGN: Retrospective cohort study of an 18-month period. SETTING: An urban primary care practice. PATIENTS: A random sample (N = 477) of patients who were seen at least twice during the study period. MAIN OUTCOME MEASURES: Number of missed visits and kept visits, insurer, age, sex, race, ZIP code, and diagnoses. RESULTS: Of the established patients, 48% missed 1 or more visits. Patients in managed care programs, private and Medicaid, were likely to have missed more visits during the study period than those not in managed care programs (P < .001). Medicaid managed care patients had also scheduled more visits. Significantly higher rates of missed appointments were found in patients aged 19 to 35 years (P = .02), blacks (P < .001), patients in Medicaid managed care programs (P < .001), and patients who scheduled more visits (P < .001). After adjusting for age, race, and sex, Medicaid managed care insurance remained a significant (P < .01) predictor of rate of missed appointments. CONCLUSIONS: Patients in managed care programs missed more appointments. Patients in Medicaid managed care programs scheduled more appointments and had higher rates of missed appointments than their counterparts in other insurance groups.

Adult↗