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Results for “Preferred Provider Organizations”

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At least 163 records · Page 9Linked to original sources

PubMed1994

Managed care: an opportunity for osteopathic physicians.

Managed care plans now enroll 38.6 million persons in the United States, and have increased their enrollment 14-fold in 5 years. The three major health reform proposals before Congress presently make managed care organizations, in one form or another, the linchpin of their reform plans. The authors trace the history of managed care leading to today's spectrum of plans from health maintenance organizations to preferred provider organizations with all their variants. They examine the government and insurance industry records of successes and failures and project the future for managed care with and without government-imposed healthcare reform. They unscramble the "alphabet soup" and detail the problems physicians have encountered in managed care settings. Given the key role of the primary care physician, the authors urge osteopathic physicians to take a proactive role in designing the shift to managed care. By supporting intelligent healthcare reform that brings physicians, hospitals, and insurers together in a practitioner-friendly system, the primary care physician can assume the leadership role in managed care and continue to serve as the patient advocate.

Health Care Reform↗

PubMedDate not supplied

Managed health care plans in Southern United States municipalities: empirical evidence on choice of plan.

This study examines factors that influence choice of Southern municipal government health care plans in the United States. Using survey data, this article specifically examines the managed care offerings of Health Maintenance Organizations (HMO), Preferred Provider Organizations (PPO) and Point of Service (POS) plans. Some of the more interesting empirical results indicate that HMO plans are associated more with employee satisfaction; PPO plans are associated with cost containment; and POS plans are more likely to provide health care benefits to part-time employees. Empirical evidence also indicates that employee satisfaction is increased when there is a greater choice of managed care plans available to municipal governments.

Administrative Personnel↗

PubMed1993

Ectopic pregnancy in the United States: economic consequences and payment source trends.

OBJECTIVE: To estimate the annual direct and indirect costs of ectopic pregnancy in the United States and to examine trends in payment source. METHODS: We analyzed hospital discharge data for 1982-1989 from a San Francisco hospital and California statewide data for 1983-1987 to estimate direct medical care costs and to determine payment sources. Examination of national labor data was used to compute indirect cost. RESULTS: The total cost of ectopic pregnancy in 1990 was estimated to be nearly $1.1 billion. Direct costs of hospitalization and other medical treatment contributed 77% of the total costs, with average hospital costs estimated to be $6079, hospitalization-related physician fees $3254, and average outpatient costs $149, for a total direct cost-per-case of $9482. Of the total indirect costs ($250.5 million), 67% was attributed to the value of lost wages and the remainder to the lost value of household management. Public payment sources covered the largest portion of ectopic pregnancy-related direct costs among women aged 19 and younger (35%), but private insurance covered the largest portion among women aged 20-29 (32%) and women aged 30 and older (43%). In general, the proportion of payments made by private insurance has decreased, while the proportion of payments made by public pay sources and health maintenance organizations and preferred provider organizations has increased. CONCLUSIONS: Ectopic pregnancy results in a substantial economic burden, with an increasing share of direct costs being borne by public pay sources. Appropriate use of cost-effective management approaches can reduce costs, while preventive measures that decrease the risk of ectopic pregnancy can both save resources and, more important, spare human suffering.

Adolescent↗

PubMed2002

Diabetes disease management in a community-based setting.

PURPOSE: The medical cost of diabetes in the United States in 1997 was at least $98 billion. This study illustrates the behavioral change and medical-care utilization impact that occurs in a community-based setting of a diabetes disease-management program that is applied to program participants in a health insurance plan's health maintenance organization and preferred provider organization. DESIGN: A historical control comparison of diabetes-management participants. METHODOLOGY: One hundred twenty-seven identified diabetes patients are followed from baseline through 1 year. Differences in behavior are compared at program intake and at a 6-month reassessment. Differences in medical-service utilization are compared in the baseline year and the year subsequent to program enrollment. Poisson multivariate-regression models are estimated for counts of inpatient, emergency department, physician evaluation and management, and facility visits, while also controlling for potential confounders. PRINCIPAL FINDINGS: Behaviors improved between program intake and the 6-month reassessment. From patient reports, the number of participants having a hemoglobin A1c test increased by 44.9 percent (p < .001), and there was a 53.2-percent decrease in symptoms of hyperglycemia (p = .002). From medical claims after program enrollment, a drop occurred during the program year in every dimension of medical-service utilization. Regression results show that in-patient admissions decreased by 391 (p < .001) per 1,000 for each group, while controlling for age, length of membership, and the number of comorbid claims for congestive heart failure. In the analysis of costs that were pre- and post-enrollment, which included disease-management program costs, a 4.34:1 return on investment was calculated. CONCLUSION: The diabetes program provides patients with comprehensive information and counseling relative to practicing self-management of diabetes through a number of integrated program components. This study strongly suggests that the implementation of such a program is associated with positive behavioral change and, thus, with substantial reduction in medical-service utilization. In addition, the intervention resulted in a net decrease in direct medical costs.

Aged↗

PubMed2004

Are healthier older adults choosing managed care?

PURPOSE: We attempt to determine whether older workers and early retirees avoid managed care plans and to explore whether health plan choices are linked to the health status of workers or their spouses. DESIGN AND METHODS: We use the responses of those born between 1931 and 1941 to the 1994 and 1998 waves of the Health and Retirement Survey. We analyze current workers and early retirees separately, using cross-tabular and multinomial logit techniques. RESULTS: Among older adults with active worker coverage, 60% were enrolled in either a health maintenance organization or preferred provider organization in 1998; 42% of early retirees were enrolled in these plans. Those with a choice of plans were even more likely to be in managed care. When demographic characteristics, time, and differences in the benefits and cost of the various plans offered by an employer are controlled for, health status (measured in a variety of ways) has little bearing on an older worker's choice of health plan. IMPLICATIONS: These findings suggest that older workers choose plans much as younger workers do. Employers are likely to continue to offer managed care as their workers age. The lack of unidirectional findings on health status bodes well for the long-term practicality of managed care under Medicare. Many workers are choosing an insurance type early in their tenure and remaining with that type of plan as they age.

Age Factors↗

PubMed1985

Using case-mix information to evaluate the feasibility of a PPO.

Considering whether or not to organize a preferred provider organization is a complex task. Managers will need to address many financial, legal, marketing, and organizational issues. In this case study, case-mix management information is used to address issues such as, types of patients to attract, businesses and insurance companies to include, physicians to recruit, and prices to charge, to enable the manager to make more informed decisions.

Catchment Area, Health↗

PubMed1995

Hospitals contracting with managed care.

It has been observed that enrollees in managed care systems such as health maintenance organizations (HMOs) and preferred provider organizations (PPOs) have lower utilization rates and lower expenditures than those in conventional fee-for-service health insurance programs. To date, no study has investigated this issue by examining providers. This paper studies whether lower cost hospitals are more likely to sign contracts with HMOs and PPOs and thus explain the observed lower utilization rates and lower expenditures by HMO and PPO enrollees. A logistic regression is applied to the data from the 1988 AHA Annual Survey of Hospitals. The results show that private hospitals, teaching hospitals, hospitals accredited by JCAHO, hospitals with high case mix index, and hospitals located in MSAs are more likely to contract with HMOs and PPOs than their counterparts. If hospitals with these characteristics have higher costs, then the results do not suggest that hospital costs can explain the lower utilizations and lower expenditures by HMO and PPO enrollees.

Contract Services↗

PubMed1992

Medicare and state health care programs: fraud and abuse; safe harbors for protecting health plans--HHS. Interim final rule with request for comment.

In accordance with section 14 of the Medicare and Medicaid Patient and Program Protection Act of 1987, this interim final rule establishes two new safe harbors and amends one existing safe harbor to provide protection for certain health care plans, such as health maintenance organizations and preferred provider organizations. The first new provision protects certain incentives to enrollees (including waiver of coinsurance and deductible amounts) paid by health care plans. The second new provision protects certain negotiated price reduction agreements between health care plans and contract health care providers. Finally, an existing safe harbor has been amended to protect certain agreements entered into between hospitals and Medicare SELECT insurers. These safe harbors specifically set forth various standards and guidelines that, if met, will result in the particular arrangement being protected from criminal prosecution or civil sanctions under the anti-kickback provisions of the statute.

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

PubMed1989

A new perspective on nursing and caring in a corporate context.

An understanding of how the corporatization of the health care system has influenced the social context of health workers is essential as nurses attempt to implement an ethic of caring. Since the 1960s, the US health care system has been moving toward increased competition between providers and toward care-avoidance incentives. These incentives created by the Medicare Prospective Payment Systems based on diagnosis related groups, health maintenance organizations, and preferred provider organizations reward the minimization of service. In this context, nurses are not rewarded for trying to care. However, nurses can employ various strategies in nursing education, health care policy formation, and social activism to insist that caring is a nonnegotiable component of nursing work.

Delivery of Health Care↗

PubMed2003

Finance issue brief: any willing provider: year end report-2003.

Today, almost half the states have laws obligating managed care organizations (MCOs) such as health maintenance organizations (HMOs) and preferred provider organizations (PPOs) to contract with any willing health care provider. Although most provisions are limited to pharmacies or pharmacists, several states have adopted broad provisions applying to hospitals, physicians, chiropractors, pharmacists, podiatrists, therapists and nurses.

Contract Services↗

PubMed1990

Use of a preferred provider plan by employees of the City of Seattle.

Little is known about the use of services in a preferred provider organization (PPO). We studied a preferred provider arrangement between Pacific Medical Center and employees of the City of Seattle. In the second 12 months of this program 8,529 subjects submitted at least one claim; of these, only 420 (4.9%) ever used the preferred provider. Those who used the PPO at least once differed significantly from those who never used it on age, sex, employee/dependent status, and utilization in the previous year. Outpatient and total charges were higher for PPO users than for nonusers before and after control for those characteristics. Those who used the PPO exclusively were similar to those who never used it. People who used both the PPO and other providers were at higher risk for use of services, and had much higher overall utilization, with or without control for other variables. No differences were found between people who obtained only a small proportion of their services at the PPO and those who had most (but not all) of their use at the PPO. Many of these findings can be explained by a self-selection model. It is important for research on PPOs to have an independent manner of assessing who is a PPO user.

Adolescent↗

PubMed1987

Revitalizing the district model for the delivery of prevention-focused community health nursing services.

The Block Nurse Program addresses the need to contain health care costs, prevent disability resulting from chronic illness, and promote the health of the elderly population. It provides community-based care and focuses on disease prevention and decreased use of institutional care. Because the block nurse model is neighborhood based, the program is decentralized and geographically specific. These characteristics, when juxtaposed with the often depersonalized and fragmented megacorporate health maintenance organizations and preferred provider organizations, have great public appeal. Block nursing allows for the individualized care that many fear will be lost in the current corporate organization of our health care system.

Aged↗

PubMed1997

Foster Higgins National Survey: trends in behavioral benefits.

Most employer-sponsored health insurance plans provide some coverage for mental health and addiction treatment. However, analysis of over 3,000 employer benefit plans reveals wide variation in the level and scope of behavioral health benefits. Of all commercially insured employees and dependents, 77 percent are currently enrolled in health maintenance organizations (HMOs), preferred provider organizations (PPOs), or point-of-service (POS) managed care plans. This article documents the differences among behavioral health coverage packages in these three different types of managed care organizations (MCOs), and the lower levels of behavioral health coverage compared with coverage for other medical care. The author states that some employers are selecting single-specialty managed behavioral carve-out plans specifically to increase benefit levels and improve quality of care.

Cost Control↗

PubMed1988

How to survive in the private practice of psychiatry.

The private practice of psychiatry is being transformed by the new economics of medical care. Patients are paying more out-of-pocket for necessary care (demand-side cost sharing), and health care providers are being asked to assume part of the risk of treatment through prospective payment (supply-side cost sharing). Specific survival strategies for psychiatrists in private practice include development of a balanced practice, expansion of referral networks, participation in alternative delivery systems such as health maintenance organizations and preferred provider organizations, active involvement in utilization and claims review, participation in outcome studies, and expansion of patient care advocacy and community involvement.

Health Maintenance Organizations↗

PubMed1987

Joint ventures: a risk to the ministry's moral capital?

When Catholic health care providers become involved in a joint venture, they put at risk not only their financial and legal resources but also their "moral capital," that is, their tradition of healing in Jesus Christ's name. Since collaborative arrangements may offer the only way to respond to persons in need, organizations that are contemplating joint ventures must assess in moral terms the "return" on such arrangements. The joint ventures fraught with the greatest moral risk are those between hospitals and physicians. In such arrangements, the patient's best interests may be compromised by the economic interests of both the physicians and the provider. Although both the law and the American Medical Association seem reluctant to prohibit entrepreneurial activity that places physicians in conflict-of-interest situations, they have established disclosure requirements to help safeguard patient interests. Moral tensions also are inherent in managed care plans such as health maintenance organizations and preferred provider organizations. The emphasis on gatekeeping to avoid unnecessary medical procedures and the potential for excluding persons in need who cannot afford to participate in such plans are two serious concerns. The patient's right to confidentiality also may be threatened in capitated systems, which rely on complex utilization review procedures that expose the patient's records to a wide circle of people. Each ethical issue will not arise in every potential joint venture. The sooner an organization can name the key values it wants to protect, however, the easier it will be for potential partners to work together and to build into the joint venture safeguards for these values.

Catholicism↗

PubMedDate not supplied

Medicare managed care: past, present, and future.

Medicare managed care enrollment has mushroomed in the past few years, tripling from 1993 to 1997. The payment rates have allowed plans to offer valuable extra benefits to beneficiaries at little or no additional cost; employers have provided inducements for their retirees to enroll; and many of the new Medicare beneficiaries are already in managed care plans when they enter the program. The Balanced Budget Act of 1997 and other factors could cause enrollment trends to change in either direction. More kinds of plans, including physician service organizations and preferred provider organizations, may be more attractive; new educational efforts may make more beneficiaries aware of managed care plans; and employers may continue to move their retirees into managed care. On the other hand, lower than expected Medicare payment rates to the plans may reduce the additional benefits they offer; consumer dissatisfaction with managed care is growing; and employers are dropping retiree benefits altogether. The future of Medicare managed care is hard to predict.

History, 20th Century↗

PubMed1986

HMOs and PPOs in review.

The growth of health maintenance organizations (HMOs) and preferred provider organizations (PPOs) has continued in the past 3 months, marked by both an increase in numbers and enrollment. Independent practice associations (IPAs) have taken the lead as the dominant model type. The intensified activity and growth in HMOs have resulted in considerable discussion centering on cost containment and quality of care issues. Employers, enrollees, the Health Care Financing Administration, and the HMOs, each with its own vested interest in these issues, attempt to resolve the conflicts between the cost and quality of healthcare in prepaid plans.

Cost Control↗

PubMed1986

Identifying incremental cost in HMO/PPO bid evaluation.

While hospitals are implementing case-mix accounting systems, they also may be negotiating prices with health maintenance organizations (HMOs) and preferred provider organizations (PPOs). To aid decision makers in their evaluation of HMO/PPO bids, a matrix that projects the bottom-line effect of various rate and volume options may be useful. Identifying incremental cost--the additional cost incurred if one patient day were added--is the key to this type of matrix analysis. Knowing incremental cost, financial managers can project the effect of a potential loss of current patient volume if a bid is rejected, as well as the effect of a potential shift of patients to HMO/PPO status if a bid is accepted. Although the incremental per diem cost is of chief importance in evaluating bid alternatives, other factors, such as the hospital's potential for growth, opportunity to increase its competitive position, and the impact on community relations and on the medical staff, also must be considered.

Accounting↗