Helping clients with HIV disease navigate managed care

The transition of medical care from fee-for-service to managed care is having an impact on health and mental health practitioners who provide care to people with HIV and AIDS. Evidence suggests that the quality of managed care is not adequate for older patients and patients with chronic diseases. Satisfaction with a managed care plan is often linked to perception of the plan's convenience, the relationship with one's primary health care provider, and the limits on out-of-pocket expenses. Dissatisfaction is linked to inefficient service, limits on choice of provider, and substandard care. The experiences of mental health care providers and recipients in the managed care system are discussed. Advocates note enhanced communication among health care providers and opponents voice concerns about regulation. The greatest concern is that treatment decisions will be based on factors other than the client's needs and best interests. Managed care has the potential to constrain psychotherapeutic treatment, however, understanding managed care plans can result in creative treatment approaches and strategies.     

Quality and accountability: Children's emergency services in a managed care environment

The fast pace of change in the health care system has sparked growing interest among purchasers, consumers, providers, health plans, and others in evaluating and improving the quality of health services. The Emergency Medical Services for Children Program's Managed Care Task Force recommended the development of a white paper to focus on issues related to quality and accountability in children's emergency medical services in a managed care environment. A literature review was conducted, and a panel reviewed and discussed relevant materials. The panelists then developed recommendations as a resource for managed care organizations, providers of care, professional associations, and federal, state, and local policymakers.     

Clearinghouse: managed care

References to papers on managed care cost effectiveness, training, and patient empowerment in the mental, physical health, and HIV/AIDS arenas are provided. Organizations that provide information on managed care for people with HIV in Washington, DC, Sunnyvale, CA, and New York City are listed.     

Practice guidelines and performance measures in emergency medical services for children

Practice guidelines and performance measures are critical elements of an effective quality improvement process for emergency medical services for children (EMSC). Practice guidelines address the clinical management of individual patients, and performance measures assess the quality of care delivered to a population. The public and private sectors have invested considerable resources in developing practice guidelines and performance measures to improve the quality of health care services. As organizations continue development efforts, health care professionals who are actively involved in emergency care must collaborate to develop guidelines that address the unique physiologic, psychologic, and cultural needs of children. The Emergency Medical Services for Children Managed Care Task Force recommended the development of a series of white papers to focus on issues related to practice guidelines and performance measures in EMSC. The Maternal and Child Health Bureau, Health Resources and Services Administration, the National Highway Traffic Safety Administration, and the Robert Wood Johnson Foundation jointly sponsored the project. The paper was developed by a panel selected from a pool of experts in managed care, quality improvement, and emergency medical services. After a review of the literature, the panelists met to discuss critical issues related to practice guidelines and performance measures in EMSC. The panelists developed recommendations that can serve as resources for managed care organizations, health care providers, professional associations, and governmental policy makers. The panel recognized the lack of nationally recognized pediatric emergency care guidelines and performance measures and called for immediate action in these areas.     

Quality and Accountability: Children’s Emergency Services in a Managed Care Environment

The fast pace of change in the health care system has sparked growing interest among purchasers, consumers, providers, health plans, and others in evaluating and improving the quality of health services. The Emergency Medical Services for Children Program’s Managed Care Task Force recommended the development of a white paper to focus on issues related to quality and accountability in children’s emergency medical services in a managed care environment. A literature review was conducted, and a panel reviewed and discussed relevant materials. The panelists then developed recommendations as a resource for managed care organizations, providers of care, professional associations, and federal, state, and local policymakers. [Moody-Williams JD, Dawson D, Miller DR, Schafermeyer RW, Wright J, Athey J: Quality and accountability: Children’s emergency services in a managed care environment. Ann Emerg Med December 1999;34:753-760.]     

The Impact of Publicly Funded Managed Care on Adolescent Substance Abuse Treatment Outcomes

This study compares the 12-month changes in substance use following admission to substance abuse treatment in Massachusetts between adolescents enrolled in Medicaid managed care and other publicly funded adolescents. Two hundred and fifty-five adolescents were interviewed as they entered substance abuse treatment and at 6 and 12 month follow-ups. Medicaid enrollment data were used to determine the managed care enrollment status. One hundred forty two (56%) adolescents were in the managed care group and 113 (44%) comprise the comparison group. Substance use outcomes include a count of negative consequences of substance use, days of alcohol use, days of cannabis use, and days of any substance use in the previous 30 days. Repeated measures analysis of covariance (ANCOVA) was used to assess change with time of measurement and managed care status as main effects and the interaction of time and managed care included to measure differences between the groups over time. Although several changes across time were detected for all four outcomes, we found no evidence of an impact of managed care for any of the outcomes. The results of our study do not support the fears that behavioral managed care, by imposing limits on services provided, would substantially reduce the effectiveness of substance abuse treatment for adolescents. At the same time, the results do not support those who believe that the continuity of care and improved resource utilization claimed for managed care would improve outcomes.     

The impact of publicly funded managed care on adolescent substance abuse treatment outcomes

This study compares the 12-month changes in substance use following admission to substance abuse treatment in Massachusetts between adolescents enrolled in Medicaid managed care and other publicly funded adolescents. Two hundred and fifty-five adolescents were interviewed as they entered substance abuse treatment and at 6 and 12 month follow-ups. Medicaid enrollment data were used to determine the managed care enrollment status. One hundred forty two (56%) adolescents were in the managed care group and 113 (44%) comprise the comparison group. Substance use outcomes include a count of negative consequences of substance use, days of alcohol use, days of cannabis use, and days of any substance use in the previous 30 days. Repeated measures analysis of covariance (ANCOVA) was used to assess change with time of measurement and managed care status as main effects and the interaction of time and managed care included to measure differences between the groups over time. Although several changes across time were detected for all four outcomes, we found no evidence of an impact of managed care for any of the outcomes. The results of our study do not support the fears that behavioral managed care, by imposing limits on services provided, would substantially reduce the effectiveness of substance abuse treatment for adolescents. At the same time, the results do not support those who believe that the continuity of care and improved resource utilization claimed for managed care would improve outcomes.     

Managed long-term care: limits and lessons

In the mid-1990s, states began to reduce their reliance on commercial health plans in the primary and acute care markets. At the same time, however, many states are for the first time encouraging these plans to participate in long-term care programs. The evidence suggests, however, that commercial health plans will not provide a quick cure to the long-term care system. At the same time, several states have managed long-term care initiatives that do not rely on commercial health plans but that do an excellent job of case management and that also seem to be among the national leaders in offering home and community-based services. Oregon provides one example, but so does the traditional managed long-term care system in Arizona and the Community Options Program in Wisconsin. The current efforts in Arizona and Wisconsin to abandon these models and to embrace competition may therefore be a mistake.     

The Cleveland Alzheimer's managed care demonstration: outcomes after 12 months of implementation

PURPOSE: This demonstration evaluates the effects of integrating Alzheimer's Association care consultation service with health care services offered by a large managed care system. The primary hypothesis is that Association care consultation will decrease service utilization, increase satisfaction with managed care, and decrease caregiver depression and care-related strain. Secondary modifying-effects hypotheses posit that the effects of the intervention will be intensified when patients have not received a firm dementia diagnosis, patients have more severe memory problems, caregivers use other Association services in tandem with care consultation, and caregivers are not patients' spouses. DESIGN AND METHODS: The demonstration is a randomized trial that examines outcomes after a 12-month study period. Interview data from 157 primary family caregivers are combined with data abstracted from medical/administrative records. RESULTS: Support for the primary hypothesis is found for selected, but not all, service utilization outcomes and for caregiver depression. Support for secondary modifying-effects hypotheses is found for satisfaction outcomes and care-related strain outcomes. IMPLICATIONS: Care consultation delivered within a partnership between a managed care health system and an Alzheimer's Association is a promising strategy for improving selected outcomes for patients with dementia and their caregivers.     

Obesogenic behaviours in South Asian adolescents in England: a literature review and quantitative investigation

BackgroundWHO has stated that childhood obesity is one of the most serious challenges facing public health in the 21st century, with obese children and adolescents facing a plethora of health complications and increased risk of many chronic diseases. Using a literature review and quantitative analysis of the WHO Health Behaviour in School-Aged Children (HBSC) data, we aimed to better understand obesogenic behaviours in South Asian adolescents in England.MethodsWe searched electronic databases (Embase, Scopus, Medline, Web of Science) from inception of the database to April 10, 2016, and the references of relevant papers. Grey literature including reports and non-peer reviewed sources were also included. Inclusion criteria were: adolescents aged 11–18 years of age, articles in English language, and studies based in England. Quantitative analysis of HBSC data from 2010 examined variables such as physical activity, dietary behaviours, and mental health indicators. We compared adolescents from Bangladeshi, Indian, and Pakistani groups for each variable, by sex, with white British adolescents. Pearson's χ² test was carried out to compare all groups against each other. Ethics approval was given by the University of Hertfordshire Ethics committee for Health and Human Sciences (HSK/SF/UH/00007). Ethical sensitivity was also enhanced through the work of reference groups with young people, which informed the conduct of the study within schools.FindingsThe HSBC 2010 sample consisted of 51 Bangladeshi, 96 Indian, 111 Pakistani, and 3476 white British adolescents. Two (8·7%) of 23 Bangladeshi girls undertook 5 or more days' physical activity, compared with 744 (44·1%) of 1688 white British girls, 13 (27·7%) of 47 Indian girls, and 16 (33·3%) of 48 Pakistani girls. South Asian adolescents had significantly worse outcomes in terms of number of times physical activity was undertaken per week (p=0·023) or any physical activity in the previous 7 days (p=0·002). 11 (20·0%) of 55 Pakistani girls never ate vegetables or ate them less than once a week, compared with 94 (5·3%) of 1771 white British girls (consumption of vegetables, p<0·0005).InterpretationKey findings from the literature review and HBSC 2010 data were that South Asian adolescents have lower physical activity levels compared with their white peers, have worse dietary behaviours, and have barriers to engaging in healthier lifestyles, compared with their white British counterparts. These negative lifestyle behaviours will need careful consideration of upstream policy and local health service provision and interventions in South Asian adolescents in England. Taking this evidence into action will be crucial to address the obesity epidemic and reduce existing health inequalities.FundingNone.     

Single-payer national health insurance. Physicians' views

BACKGROUND: Forty-one million Americans have no health insurance and, despite the growth of managed care, medical costs are again increasing rapidly. One proposed solution is a single-payer health care financing system with universal coverage. Yet, physicians' views of such a system have not been well studied. METHODS: We surveyed a random sample of physicians (from the American Medical Association Masterfile) in Massachusetts, regarding their views on a single-payer health care financing system and other financing and physician work-life issues that such a system might affect. RESULTS: Of 1787 physicians, 904 (50.6%) responded to our survey. When asked which structure would provide the best care for the most people for a fixed amount of money, 63.5% of physicians chose a single-payer system; 10.7%, managed care; and 25.8%, a fee-for-service system. Only 51.9% believed that most physician colleagues would support a single-payer system. Most respondents would give up income to reduce paperwork, agree that it is government's responsibility to ensure the provision of medical care, believe that insurance firms should not play a major role in health care delivery, and would prefer to work under a salary system. CONCLUSIONS: Most physicians in Massachusetts, a state with a high managed care penetration, believe that single-payer financing of health care with universal coverage would provide the best care for the most people, compared with a managed care or fee-for-service system. Physicians' advocacy of single-payer national health insurance could catalyze a renewed push for its adoption.     

The future of physician's time

Physicians' time is under assault in the current health care system. In particular, managed care payers are reducing compensation to physicians on a discounted fee-for-service basis. More demanding consumers, complex new technologies, and increased managerial and administrative burdens are placing further constraints on physicians' time. As we look ahead, it seems likely that these pressures will intensify and transform the ways in which physicians spend their time. Physicians will play eight key roles in the future: clinical data collector, shaman, health advisor and wellness coach, knowledge navigator, proceduralist, diagnostician, physician manager, and quality assurance specialist. They will need to lead the redesign of these roles and define the ways in which they should spend their time in the health care system of the new millennium.     

Twenty-four-hour access to emergency care for children in managed care

Children's medical emergencies occur around the clock. In years past, the emergency department, open 24 hours a day, was a familiar site for treating these emergencies. However, in today's health care environment, the scenario can be more confusing. As many families move from a fee-for-service system into a managed care organization (MCO), they may be unclear about what they should do in an emergency involving their child. MCOs want to provide appropriate care, and at the same time, operate within a system designed to contain costs through the establishment of effective health care delivery systems. Providers of emergency services, including specialists in pediatric medicine and emergency medical services responders, also must contend with a different set of problems, including administrative entanglements and concerns about reimbursement for their services. This article continues the white paper series by the Emergency Medical Services for Children Managed Care Task Force.     

Managed care and the geriatric patient-physician relationship

As managed care proliferates in the United States and other countries, its structure has patterned changes in patient-doctor relationships, including those between older patients and their physicians. The physician as gatekeeper now limits the access of the patient to information and services. Patient trust in the physician, essential to an effective patient-doctor relationship, will be damaged under this system of care. Additionally, examples from medical encounters demonstrate that many of the problems in the doctor-older patient relationship found under fee for service will remain, including the lack of attention to the contextual issues of health care of older adults.     

Some implications of managed care for physician assistants

The American health industry is now focusing on managed care, capitated payment, and the formation of regional networks. As a result, additional cost constraints in the delivery of our nation's health services should be expected. Such proposals are also anticipated to have a major impact on PAs: (a) there will be an increased demand for qualified PAs to provide primary care services; (b) PAs will be better positioned for advancement than other health professionals despite industry-wide cost-containment efforts; and (c) most PAs can expect to practice in less "user-friendly" environments, irrespective of the implementation of the procompetitive concept of managed care or more regulatory global budgetary targets.     

Managed care, attitudes, and career choices of internal medicine residents

The influence of managed care on internal medicine residents' attitudes and career choices has not yet been determined and could be substantial. In a survey of 1,390 third-year internal medicine residents, 21% believed that managed care was the best model of health care for the United States, and 31% stated they would be satisfied working in a managed care system. Those from high managed care communities (>30% penetration) were only slightly more accepting of managed care, but were more likely to choose general internal medicine as a career (54%, p = .0009) than those from communities with lower managed care penetration.     

Good managed care needs universal health insurance

Although the increase of corporate managed care has helped to reduce excesses and costs, continued gains in cost-effectiveness depend on good clinically managed care. Benefits of clinically managed care depend on stable contracts and universal coverage. Instead, employers are decreasing coverage and creating a market of "lemons" in which low-cost plans are rewarded for cost-cutting tactics. These tactics have spawned movements that demand rights for patients and providers. Choosing to shore up those rights, however, will increase the number of uninsured persons. This tragic choice, which no other industrialized nation has permitted, will not be resolved until some form of universal health insurance is implemented.     

Organizational and financial characteristics of health plans: are they related to primary care performance?

BACKGROUND: Primary care performance has been shown to differ under different models of health care delivery, even among various models of managed care. Pervasive changes in our nation's health care delivery systems, including the emergence of new forms of managed care, compel more current data. OBJECTIVE: To compare the primary care received by patients in each of 5 models of managed care (managed indemnity, point of service, network-model health maintenance organization [HMO], group-model HMO, and staff-model HMO) and identify specific characteristics of health plans associated with performance differences. METHODS: Cross-sectional observational study of Massachusetts adults who reported having a regular personal physician and for whom plan-type was known (n = 6018). Participants completed a validated questionnaire measuring 7 defining characteristics of primary care. Senior health plan executives provided information about financial and nonfinancial features of the plan's contractual arrangements with physicians. RESULTS: The managed indemnity system performed most favorably, with the highest adjusted mean scores for 8 of 10 measures (P<.05). Point of service and network-model HMO performance equaled the indemnity system on many measures. Staff-model HMOs performed least favorably, with adjusted mean scores that were lowest or statistically equivalent to the lowest score on all 10 scales. Among network-model HMOs, several features of the plan's contractual arrangement with physicians (ie, capitated physician payment, extensive use of clinical practice guidelines, financial incentives concerning patient satisfaction) were significantly associated with performance (P<.05). CONCLUSIONS: With US employers and purchasers having largely rejected traditional indemnity insurance as unaffordable, the results suggest that the current momentum toward open-model managed care plans is consistent with goals for high-quality primary care, but that the effects of specific financial and nonfinancial incentives used by plans must continue to be examined.     

Models of Care for addressing chronic musculoskeletal pain and health in children and adolescents

Chronic musculoskeletal pain among children and adolescents is common and can negatively affect quality of life. It also represents a high burden on the health system. Effective models of care for addressing the prevention and management of pediatric musculoskeletal pain are imperative. This chapter will address the following key questions:(1) Why are pediatric-specific models of pain care needed?(2) What is the burden of chronic musculoskeletal pain among children and adolescents?(3) What are the best practice approaches for early identification and prevention of chronic musculoskeletal pain in children and adolescents?(4) What are the recommended strategies for clinical management of chronic pain, including pharmacological, physical, psychological and complementary, and alternative approaches?(5) What are the most effective strategies for implementing models of pain care across different care settings?(6) What are the research priorities to improve models of care for children and adolescents with chronic musculoskeletal pain?     

Preparing for adulthood: Health care transition counseling for youth with arthritis

Objective

To determine the proportion of adolescents with arthritis who receive health care transition services and to compare the rates with those reported for adolescents with other special health care needs and adolescents with diabetes.

Methods

We used data from the 2005–2006 National Survey of Children with Special Health Care Needs. A parent/guardian identified youth ages 12–17 years with arthritis (n = 1,052), diabetes (n = 389), and special health care needs (n = 18,189). Four questions examined the extent to which providers discussed health care transition issues, including 1) transfer of care to adult providers, 2) health care needs of adults, 3) acquiring health insurance, and 4) encouraging self‐care responsibility. Bivariate comparisons assessed the associations between sociodemographic characteristics and health care transition services, and multivariate regression models compared outcomes between conditions.

Results

Many adolescents with arthritis are being encouraged to assume self‐care responsibilities (74.8%); fewer discussed how health needs will change in adulthood (52.1%), acquiring insurance (22.5%), or transferring care to a provider who sees adults (19.0%). These results are similar to youth with other special health care needs, but behind youth with diabetes.

Conclusion

Among this sample of US adolescents, many report discussions about health care needs and self‐management, but few are addressing critical aspects of the transition to adult‐oriented health care.