AHCPR-funded Rural Managed Care Centers: Report From the Field

In 1994, the Agency for Health Care Policy and Research awarded cooperative agreements to five University-based groups to promote the establishment of managed care institutions and development of rural health networks. This paper summarizes the experiences of these rural managed care centers in the first three years of this initiative. Key ingredients for achieving the project's goals that are identified by the project directors are reported as "foundations" that must be in place from the outset, or "building blocks" that can be developed along the way. The development of information systems and efforts to foster leadership in the medical community are areas in which grant funding of this type can be most effective.     

Medicaid Managed Care and Health Care for Children

Objective. Many states expanded their Medicaid managed care programs during the 1990s, causing concern about impacts on health care for affected populations. We investigate the relationship between Medicaid managed care enrollment and health care for children.
Data Sources and Measures. Repeated cross-sections of Medicaid-covered children under 18 years of age from the 1996/1997 and 1998/1999 Community Tracking Study Household Surveys ( n =2,602) matched to state-year CMS Medicaid managed care enrollment data. For each individual, we constructed measures of health care utilization (provider and emergency department visits, hospitalizations, surgeries); health care access (usual source of care, unmet medical needs, put-off needed care); and satisfaction (satisfaction overall, with doctor choice, and with last visit).
Study Design. Regression analysis of the relationship between within-state changes in Medicaid managed care enrollment rates and changes in mean utilization, access, and satisfaction measures for children covered by Medicaid, controlling for a range of potentially confounding factors.
Principal Findings. Increases in Medicaid health maintenance organization (HMO) enrollment are associated with less emergency room use, more outpatient visits, fewer hospitalizations, higher rates of reporting having put off care, and lower satisfaction with the most recent visit. Medicaid primary care case management (PCCM) plans are associated with increases in outpatient visits, but also with higher rates of reporting unmet medical needs, putting off care, and having no usual source of care.
Conclusions. Both Medicaid HMO and PCCM plans can have important impacts on health care utilization, access, and satisfaction. Some impacts may be positive (e.g., less ED use and more outpatient provider use), although concern about increasing challenges in access to care and satisfaction is also warranted.     

Nutrition and Health for Older Persons in Rural America: A Managed Care Model

Health care services and resources for older persons living in rural areas may be highly variable, and integrated service-delivery models are often lacking. This article presents a managed-care model of nutrition risk screening and intervention for older persons in rural areas. Nutrition risk screening was implemented by the Geisinger Health Care System, Danville, Pa, to target all eligible enrollees in a regional Medicare risk program. A single remote clinic site participating in the managed health care system was chosen for further study of a linked screening and case-management effort for undernourished persons. Screening and intervention at the clinic site selected for this study were guided by centralized expertise and resources. Individualized evaluation and intervention plans were developed with the aid of a dietitian and implemented by the clinic case manager. Of the 417 subjects who completed screening at the remote site, 68 met the risk criteria for undernutrition and were selected for case management. Many of the targeted persons received interventions that included evaluations by a physician or physician extender (eg, physician assistant, nurse practitioner) at the clinic and consultations with nutrition, mental health, or social services professionals. Twenty-six of the subjects who took part in the intervention completed a follow-up screening 6 months later. Ten of those persons no longer exhibited risk criteria. This demonstrates the feasibility of a linked screening and case management program for nutrition risk in the managed-care setting. J Am Diet Assoc. 1997; 97: 885-888.     

A Managed Care Perspective

This paper highlights some of the problems associated with lipid therapy in the primary and secondary prevention of cardiovascular disorders and to make some potentially useful suggestions in the context of managed care. For managed care organizations, financial and logistical issues create obstacles to the provision of primary prevention of cardiovascular disease. These current obstacles necessitate the generation of external forces, perhaps regulatory or standards agencies, that may help increase accountability in managed care organizations for midterm and distant outcomes. In contrast, the provision of secondary prevention by managed care organizations has fewer limitations. One of the major challenges in secondary prevention, however, is the low rate of physician compliance with national treatment guidelines and standards. Among possible explanations for this observation are limitations in health data collection and integration. Improvements in data management are vital to the achievement of treatment goal optimization in secondary prevention.     

管理型医疗保健模式探索

管理型医疗保健是一个综合概念,是一种集医疗服务提供和经费管理为一体的医疗保健模式,由于协调了医、患、保三方关系而备受关注。本文从国外的管理型医疗保健模式概念入手,研究其在国外的发展现状、运行规律及特点,剖析优劣之处,并通过回顾我国走过的医疗体制改革之路,结合其各阶段带有的管理型保健特征,对今后探索中国特色管理型医疗保健模式提出建议。     

Trends in Managed Care Cost Containment: An Analysis of the Managed Care Backlash

Consumer dissatisfaction with the quality and limitations of managed health care led to rapid disenrollment from managed care plans and demands for regulation between 1998 and 2003. Managed care organizations, particularly health maintenance organizations (HMOs), now face quality and coverage mandates that restrict them from using their most aggressive strategies for managing costs. This paper examines the effect of this backlash on managed care's ability to contain costs among short‐term, non‐federal hospitals between 1998 and 2008. The results show that the impact of increased HMO penetration on inpatient costs reversed over the study period, but HMOs were still effective at containing outpatient costs. These findings have important policy implications for understanding the continuing role that HMOs should play in cost containment policy and for understanding how effective the latest wave of cost containment institutions may perform in heavily regulated markets. Copyright © 2014 John Wiley & Sons, Ltd.     

Managed Health Care Association update

Recent MHCA projects--on outcomes measurement, managed-care plan performance, and managed-care accreditation--will have a significant impact on the reformed U.S. health care system.     

The Department of Managed Care

California sets a precedent again, with a bold effort to regulate the HMO industry. While the new Department of Managed Health Care is facing down 50,000 consumer gripes monthly, director Daniel Zingale intends to keep administrative red tape from overwhelming plans, patients, providers, and his department.     

Managed Care: Survival Skills for the Future

The last two decades have been a time of dramatic and consistent change in the way health care is delivered. The use of managed care strategies by health care providers impacts occupational therapy practitioners directly, yet they are often ill-prepared to respond to changes constructively. With adequate preparation, occupational therapy practitioners may not only respond to organizational change, but play a major role in helping to shape their organization's future.

This article presents and defines the major managed care strategies being utilized by health care providers and their impacts on occupational therapy practitioners. The skills and strategies occupational therapy practitioners can use to effectively respond are presented and discussed. Suggested methods for gaining these skills are included. [Article copies available for a fee from The Haworth Document Delivery Service: 1–800–342–9678. E-mail address: getinfo@haworth.com]     

Physicians Contracting with Managed Care

It has been observed that enrollees in managed care systems such as HMOs and PPOs have lower expenditures and utilization rates than those in conventional insurance plans. Few studies have investigated this issue by examining providers. This paper studies whether physicians with low costs are more likely to sign contracts with HMOs and PPOs in order to help explain the observation of lower expenditures and utilization rates by HMO and PPO enrollees. A logistic regression is applied to the data from the 198401985 Physician Practice Costs and Income Survey. The results do not show strong evidence that a physician's likelihood of contracting with HMOs and PPOs is related to the physician's practice costs and utilization decision of contracting with managed care systems are the physician's socio-demographics, the physician's practice region, and the market conditions.     

Managed Care and Employer Premiums

This paper used 1993–1997 data from medium and large size employers to examine the effects of market wide managed care penetration on the premiums paid for employer sponsored health insurance. Regressions were run for weighted average single coverage premiums and for premiums on conventional, HMO, and PPO coverage. Four findings emerged from the analysis. First, increased managed care penetration had no statistically significant effect on weighted average employer premiums. Second, higher HMO penetration resulted in lower HMO premiums but higher conventional and PPO premiums. Third, higher PPO penetration had no statistically meaningful effects across plan types. Finally, the results depended critically on whether firms offered self-insured plans. Higher levels of HMO penetration led to smaller increases in conventional and PPO premiums for firms with self-insured plans, but also yielded smaller premium reductions from HMOs relative to those with purchased coverage.     

Medicaid Managed Care and Health Care Access for Adult Beneficiaries with Disabilities

Objective. To evaluate the impact of Medicaid managed care organizations (MCO) on health care access for adults with disabilities (AWDs).
Data Sources. Mandatory and voluntary enrollment data for AWDs in Medicaid MCOs in each county were merged with the Medical Expenditure Panel Survey and the Area Resource File for 1996–2004.
Study Design. I use logit regression and two evaluation perspectives to compare access and preventive care for AWDs in Medicaid MCOs with FFS. From the state's perspective, I compare AWDs in counties with mandatory, voluntary, and no MCOs. From the enrollee's perspective, I compare AWDs who must enroll in an MCO or FFS to those who may choose between them.
Principal Findings. Mandatory MCO enrollees are 24.9 percent more likely to wait >30 minutes to see a provider, 32 percent more likely to report a problem accessing a specialist, and 10 percent less likely to receive a flu shot within the past year. These differences persist from the state evaluation perspective.
Conclusions. States should not expect a dramatic change in health care access when they implement Medicaid MCOs to deliver care to the adult disabled population. However, continued attention to specialty care access is warranted for mandatory MCO enrollees.     

Consensus Report of the Academy of Nutrition and Dietetics: Incorporating Genetic Testing into Nutrition Care

Personalization of nutrition advice is a process already familiar to registered dietitian nutritionists, but it is not yet clear whether incorporating genetic results as an added layer of precision improves nutrition-related outcomes. Therefore, an independent workgroup of experts, supported by the Academy’s Evidence Analysis Center staff, conducted a systematic review to examine the level of evidence measuring the effect of incorporating genetic testing results into nutrition counseling and care, compared to an alternative intervention or control group, on nutrition-related outcomes. This systematic review revealed that only weak quality evidence is available in the scientific literature and observed that this field is still maturing. Therefore, at present, there is insufficient scientific evidence to determine whether there are effects of incorporating genetic testing into nutrition practice. The workgroup prepared this Consensus Report based on this systematic review to provide considerations for the practical application of incorporating genetic testing into the nutrition care process.