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Results for “Managed Care Programs”

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At least 19 recordsLinked to original sources
PubMed1992

Initial level of care and clinical status in a managed mental health program.

Data from 9,055 adult intakes performed over two and a half years of a managed mental health care demonstration project in a large U.S. city were used as indirect measures of quality of care. The level of care to which patients were initially assigned was examined in relation to the patients' clinical status as judged by both managed care case managers and treatment providers. During the period, assignment to inpatient care of patients in almost every clinical category decreased. The decrease seemed to reflect a policy decision to limit use of all inpatient services rather than a selective elimination of unnecessary hospitalization. Case managers rated a smaller proportion of patients severely disturbed, partial hospitalization was rarely used as an alternative to inpatient care, and detoxification services were increasingly used as an inpatient alternative. Although these data reinforce common beliefs about managed care, the quality of managed care programs can be accurately assessed only with data collected specifically for evaluation purposes.

Alcoholism↗
PubMed1992

Healthchoice: a managed health-care program for low-income uninsured workers.

The period in which we practice medicine is unprecedented in terms of the enormous changes that are taking place within the profession. Perhaps foremost among the changes is the manner in which the practice of medicine is organized. Historically, over the last 30 years we have witnessed the transition of substantial proportions of physicians as solo practitioners to professionals employed in one form or another by institutional management care systems. Further, from all indications, this change is continuing unabatedly. There are now more than 600 health maintenance organizations (HMOs), and their enrollment rates have been steadily increasing. More than 60 million Americans or about 30% of the insured population receive their medical care through HMOs and preferred provider organizations (PPOs). Moreover, it is estimated that in the year 2000, 90% of all Americans will be receiving their medical care from managed care systems. Clearly, the driving force behind these changes is the desire of third-party payers and the public at large to control health-care costs. We, of course, share this goal and are committed to working with the public and private sectors to accomplish this aim. Deborah L. Scott, director of the Wayne County Patient Care Management Systems, writes about HealthChoice, a model managed-care program in Detroit, Michigan. Ms Scott's article is being published in lieu of the President's Column.

Female↗
PubMed1991

Rollover effects in gatekeeper programs: cushioning the impact of restricted choice.

Public and private medical care plans that restrict the beneficiary's choice of providers have experienced rapid growth in the past decade as a means to contain costs and coordinate care. Such plans have been criticized for engendering beneficiary dissatisfaction and potentially impeding access to necessary care. Some of the objections to primary care "gatekeeping" may be diminished by recruiting the physician who served previously as the beneficiary's "usual source of care" to assume the role of formal gatekeeper. This study examines how persons whose gatekeepers were their regular source of care before plan implementation differed in their use and satisfaction from persons required to change their regular source of care. Our findings indicate that satisfaction was significantly higher among individuals who experienced no change in usual source of care. These individuals also tended to be less likely to use the emergency department as a source of care. Although the data are from Medicaid managed care programs, the findings may also be applicable to private sector point-of-service plans that adopt the primary care gatekeeper model.

Ambulatory Care↗
PubMed1991

Measurement and management of quality in managed care organizations: alive and improving.

Leatherman et al, Schlackman, and McGuirk-Porell et al all provide important examples of how managed care organizations (MCOs) will measure quality in this decade (except for health care status, which none have yet incorporated). All three organizations rely on insurance claims as a data source and quality management as a tool for improving quality; United Health Care and US Health-care use claims data to improve care for the entire membership, a still unrealized potential for MCOs. All three programs, relatively new, can be only minimally evaluated in terms of measurement validity, cost-efficiency, and improvement in the quality of care. The impact of such MCOs depends on policy initiatives, improvements in outcome and process measures, and MCOs' commitment to serve the total population, including the uninsured and Medicaid populations.

Health Services Research↗
PubMed1991

Quality screening and management using claims data in a managed care setting.

Quality screening and management (QSM), developed by United HealthCare Corporation for its own health plans but applicable to other settings, analyzes health care provided to an enrolled population using claims and administrative data supplemented, when necessary, with medical record review. For selected topics/conditions, QSM compares the care received by patients to that recommended by established practice guidelines and also reports and describes quality through incidence rates, condition-specific process and outcome measures, occurrence of adverse events, and use of preventive services. Results of the analyses are linked to appropriate quality management actions and are used to identify strategies for improvement. Data permit health plans to make performance comparisons on individual indicators and longitudinal comparisons on the effectiveness of quality improvement initiatives.

Humans↗
PubMed1992

Government, private health insurance, and the goal of universal health care coverage.

The Health Insurance Association of America advocates joint efforts by federal and state governments and the private sector to achieve the goal of universal access to health care. It recommends several changes in the small employer market to provide greater predictability and protection to those insured, including establishment of private, not-for-profit reinsurance organizations authorized by the states. State risk pools for uninsurable individuals who are not part of an employer group are also proposed. The federal government role would include expanding Medicaid eligibility and exempting all insured plans from state mandated benefits. HIAA's proposal also stresses the continued growth and use of managed care programs.

Cost Control↗
PubMed1992

The entrepreneurial physician.

This article draws on the experience of interviews of hundreds of physicians in the last few years. Those at mid-career have deep concerns about what lies ahead for them. A character, Dr. Charles Evans, has been created to describe some of the major possibilities being thought about and explored by physicians who believe their profession is now changing in ways they never had anticipated.

Defensive Medicine↗
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↗
PubMed1991

The final curtain?

Explore the source record for details and available documents.

Fees, Dental↗
PubMed1992

Barriers to pediatric referral in managed care systems.

Anecdotal evidence suggests that children's access to pediatric subspecialty and inpatient care is hampered by referral barriers imposed by managed care systems. To identify such barriers and determine how they affect the referral process, a sample of American Academy of Pediatrics Fellows (n = 1598) was surveyed. The response rate was 79.1% (n = 1264). Of those pediatricians in direct patient care (n = 956), 71.4% participated in a managed care plan. Pediatricians referred patients in managed care systems somewhat less frequently than in traditional pay systems: 8.7% and 6.9% referred managed care patients to subspecialists and inpatient care, respectively, less often. More than 20% and 10% of pediatricians with patients in managed care systems had at least one referral to subspecialist care and inpatient care, respectively, denied in the previous year. Pediatricians experienced more barriers in preferred provider organizations than in health maintenance organizations. These data suggest that utilization management programs, such as those used in managed care systems, may limit necessary access to pediatric subspecialty and inpatient care.

Child↗