Economics of managed care in spinal cord injury

OBJECTIVE: To determine and describe trends in economic variables related to the care of individuals with spinal cord injury (SCI) and significant changes in these trends coincident with major developments in medical care cost control. DATA SOURCES: Data from the National Spinal Cord Injury Statistical Center (NSCISC) database were used to review the economic trends in SCI management from 1973 to 1998 and their relation to managed care and other health care cost-containment measures. A panel of SCI health care specialists was interviewed to determine the appropriate data variables to be reviewed. The Shepherd Center Care Health Management Program, Atlanta, GA, is presented as an example of a fiscally successful managed care program for patients with SCI. DATA EXTRACTION: Data from the NSCISC database for the years studied were extracted and converted to a form suitable for analysis by means of the statistical software SAS. DATA SYNTHESIS: Statistical techniques included multiple regression analysis, logistic regression analysis, and model selection methods. CONCLUSIONS: Trends in economic variables, in the care of individuals with SCI show changes coincident with the introduction of Diagnostic Related Groups (DRGs) and managed care as models for provider reimbursement. Significant changes occurred in acute care charges, rehabilitation charges, length of stay, rehospitalization 1 year postinjury, time from injury to admission to a Model System, and discharges to a nursing home.     

Predictors of voluntary disenrollment from Medicare managed care

BACKGROUND: Prior research on selection bias in Medicare plans has demonstrated favorable enrollment of healthier beneficiaries, resulting in plan overpayment. However, total selection bias depends not only on who enrolls, but also on who disenrolls. Few studies examine selectivity in disenrollment; it is unclear how those who leave plans differ from those who remain. OBJECTIVE: The examination of health status and plan characteristics as potential predictors of voluntary disenrollment from Medicare managed care. RESEARCH DESIGN: Baseline data on health of Medicare managed care enrollees are from the 1998 Medicare Health Outcomes Survey, merged with data on enrollment status and plan characteristics. Beneficiary voluntary disenrollment, versus continuous enrollment, 24 months after completing the survey was modeled as a function of perceived health in 1998 and plan characteristics. The sample included 109,882 community-dwelling elderly. RESULTS: Between 1998 and 2000, 24% of Medicare managed care enrollees voluntarily disenrolled from plans. Poor perceived physical and mental health significantly increased the odds of voluntary disenrollment. Odds of disenrollment were higher for members of plans that increased premiums and had low market share between 1998 and 2000. Conversely, gaining drug coverage in a plan between 1998 and 2000 lowered the odds of disenrollment (relative to no coverage). CONCLUSION: Medicare plans experience favorable selection bias partly because sicker members are likelier to disenroll. Plan-level policies that influence market share and benefits, particularly pharmaceutical coverage, also have important effects on disenrollment, regardless of health effects. Understanding both individual and plan influences on disenrollment is critical to benefit coverage and disenrollment restriction ("lock in") policies.     

Effects of medicaid managed care on adults

BACKGROUND: Despite the rapid growth in Medicaid managed care (MMC) during the 1990s, only limited research exists on how such care affects beneficiaries. OBJECTIVE: The objective of this study was to assess how switching from a fee-for-service (FFS) delivery system to managed care affects Medicaid beneficiaries' access to, use of, quality of, and satisfaction with health care services. METHODS: Using a quasi-experimental design framework, we compared the experiences of 540 Minnesota Medicaid recipients living in counties that had switched to managed care with those of 528 recipients living in counties operating under FFS. The data for the analysis came from a 1998 survey of Minnesota Medicaid clients. Data were analyzed by logit regression. RESULTS: We find limited effects of MMC on access to, use of, quality of, and satisfaction with health care. Among others, we found no significant differences between the share of managed care and FFS enrollees (78.5% versus 76%) who had a health care visit during the last year. We also found no evidence of a significant reduction in the proportion of managed care and FFS enrollees (17.6% versus 17%) who had had a hospital stay during the past year. The results did show some negative effects of MMC on satisfaction with care, the most consistent being that managed care enrollees are somewhat less satisfied with their health care than their FFS counterparts. CONCLUSIONS: Our results suggest that a shift from FFS to MMC did not fundamentally change the patterns of health care service use, the location at which care was delivered, or quality.     

A hitchhiker's guide to competitive managed care

Competition among managed care plans features the dynamic interaction among three primary forces: delivery system integration, managed care health plan risk sharing, and purchaser activism. To evaluate the cost containment potential for a particular market, decision makers need to understand the character of provider integration, the role of managed care insurance plans, and the extent of purchaser activism in contracting with health care providers. This paper provides benchmarks that analysts can use to assess markets, and applies them to the four largest markets in Wisconsin. It concludes that competition among managed care plans can lead to cost-effective care only if purchasers respond to differences in cost, for given quality, by switching from high-priced plans to lower-priced ones.     

Satisfaction with managed care

This article reports the findings of 1996, 1997, and 1998 patient satisfaction surveys administered to managed care enrollees in Utah. More than 14,000 managed care enrollees (both Medicaid and commercial) were selected randomly and contacted by telephone. The 38-question survey was based on Health Plan Employer Data and Information Set (HEDIS) and the National Committee for Quality Assurance (NCQA) measures. Demographic differences between the commercial and Medicaid population were identified. Medicaid enrollees were found to be higher users of health care services. Individuals reporting the greatest health plan satisfaction tended to be healthier. However, Medicaid enrollees reported greater overall health plan satisfaction than commercial enrollees.     

Physician experiences with, and ratings of, managed care organizations in Massachusetts.

BACKGROUND: Physicians can provide important information about how managed care plans affect the delivery of health care. Assessments of the quality of managed care plans have rarely used physician evaluations. OBJECTIVES: To elicit physician evaluations of managed care plans and to determine factors associated with those evaluations. RESEARCH DESIGN: Physicians were asked in a mail survey to evaluate a managed care plan they were associated with. SUBJECTS: Probability sample of 1,336 physicians associated with the five largest managed care health plans in Massachusetts. MEASURES: Physicians were asked about the extent to which the management strategies used by a plan influenced their clinical behavior and about the quality of care available to their patients. RESULTS: Evaluations of the plans were significantly different among the eight units evaluated. Some differences between divisions within plans were as large as differences among plans. Physicians reported that the use of education and peer influence influenced their clinical behavior and facilitated the provision of high quality care more than did rules and regulations or financial incentives. Physicians evaluated most positively plans, which they said used educational strategies more than other plans and which used rules and regulations and financial incentives less. Physicians tended to rate staff and group model plans more positively than did other plans. CONCLUSIONS: Physicians can provide important information about the extent to which the organization and operation of managed care plans affect the provision of high quality care.     

Integrating chiropractic in managed care

Alternatives to traditional health care are emerging as an important element in the mix of services offered by managed care plans. Integrating these nontraditional services, such as chiropractic, presents special challenges for plan managers. ChiroNet, an Oregon-based chiropractic specialty PPO network, has formed partnerships with a variety of managed care plans bringing managed chiropractic services to the PPO, EPO, and HMO environments. Practical experience with benefit design, access protocols, utilization management, quality assurance, provider credentialing, and administrative integration has been developed over the period of the network's cooperation with its managed care partners. Successful integration of these nontraditional provider groups depends on alignment of goals and incentives among all players in the system, including providers, their network, the patients, and the managed care plan.     

Information and decision support in managed care

Employers are increasingly purchasing health care benefits based on value, as it relates to both current and future needs, and they are seeking managed care partners who are committed to continuous quality improvement. They realize that meaningful health care information provides an essential foundation to support the development and implementation of future strategies, rather than allowing change to occur by chance. The success of a managed care strategy depends on the employer's ability to monitor plan performance routinely and target opportunities for improvement; the managed care organization's commitment to maintain cost-effective, quality-conscious provider networks; and the providers' willingness to change their practice patterns to improve quality and outcomes.     

Successful Medicaid managed care organizations: it is not an oxymoron

Success as a Medicaid health plan is achieved by those plans with a clear understanding of Medicaid program requirements. Executives of Medicaid health plans identify four common elements that result in winning plans: (1) Leadership must have significant experience with, or otherwise develop knowledge of, the Medicaid program's regulations and populations covered; (2) the plan must have an internal managed care culture and system that integrates finance, operations, and medical management; (3) management must have access to highly specialized information and data analysis capability; (4) leadership must have well-developed relationships with key stakeholders. While these elements seem intuitive, health plans often enter the marketplace without needed groundwork firmly in place.     

Stakeholder perceptions of quality in managed care plans

Quality within managed care plans continues to be a contentious issue. This article reports on a case study undertaken to identify the importance of health plan quality attributes to three key stakeholder groups affiliated with a single plan: employers, physicians, and consumers. Findings from a representative survey of these three stakeholder groups indicate that they value different attributes, and suggest that plans must be responsive to these varying perceptions of quality.     

Beneficiary knowledge of original Medicare and Medicare managed care

BACKGROUND: Previous research on beneficiary knowledge of the Medicare program has shown that the beneficiary population is not well informed about Medicare. The Centers for Medicare & Medicaid Services (CMS) implemented the National Medicare Education Program in 1998 to educate Medicare beneficiaries about program benefits; choices, rights, responsibilities and protections, and health behaviors. OBJECTIVES: We sought to measure beneficiary knowledge of the Medicare program and to assess how knowledge varies by beneficiary subgroups and topic areas. RESEARCH DESIGN: We conducted psychometric analyses of survey data from Round 36 of the Medicare Current Beneficiary Survey to construct knowledge indices and estimated regression models with each knowledge index as the dependent variable, controlling for sociodemographic characteristics, self-reported health status, and insurance. SUBJECTS: The study sample included 2634 noninstitutionalized Medicare beneficiaries. MEASURES: There were 2 separate knowledge indices representing the 2 primary avenues for receiving Medicare benefits: Original Medicare and Medicare managed care. RESULTS: Beneficiaries ages 75 or older, nonwhite, with lower incomes, lower education levels, and public insurance had lower levels of knowledge on both indices. Enrollment in Medicare managed care was positively associated with knowledge about Medicare managed care but negatively associated with knowledge about Original Medicare. Areas of low program knowledge included coverage and benefits, enrollment/disenrollment, and plan choice. CONCLUSIONS: Our findings suggest the need to develop educational campaigns targeting vulnerable beneficiaries who have continued to demonstrate low levels of Medicare program knowledge.     

Disenrollment from an acute/long-term managed care program (PACE)

BACKGROUND: The Program of All-Inclusive Care for the Elderly (PACE) is an acute/long-term managed care plan designed to care for the most frail and vulnerable Medicare beneficiaries. To our knowledge, this is a first study to examine patterns and predictors of disenrollment from PACE. OBJECTIVE: PACE, with its comprehensive delivery system, dual capitation, and a focus on the most vulnerable population, may be expected to achieve low rates of exit and little selective dissenrollment. This study examines whether these goals have been accomplished. RESEARCH DESIGN: The study includes 30 PACE programs and 14,657 individuals enrolled in them. Individual-level records, obtained from an administrative database, contain information on sociodemographics, caregiver support, health status and disability, medical history, service utilization, and disenrollment. Program-level variables also were included. Cox proportional hazard models, with time-varying and time-invariant covariates, were employed to predict time to disenrollment. RESULTS: Our findings show a low level of disenrollment. We find no increase in disenrollment risk by age, functional or cognitive impairment, Medicaid eligibility, or diagnoses. Certain characteristics (eg, nursing treatments) appear to reduce the disenrollment hazard, whereas others (eg, hospital admissions, private pay status) significantly increase it. The risk of disenrollment also increases with longer nursing home stays, until 80-90 days, whereupon it begins to decline. CONCLUSIONS: Both enrollee and program-level attributes predict program disenrollment. Programmatic and quality of care improvements may be needed to further minimize disenrollment, particularly in programs experiencing rates that are substantially greater than the average.     

Building managed care networks for rural communities

Managed health care networks in both urban and rural communities seek to improve quality, cost, and access; however, rural community health care systems must also curb patient outmigration. A primary care network (PCN) can effectively keep more of the patient care within the rural community. This PCN can then expand to include secondary contractual relationships with the rural community hospital and specialist physicians. As this expanded PCN affiliates with a tertiary provider network, an integrated delivery system (IDS) emerges. This enables the full health care service continuum to be managed by the rural primary care physicians. Such managed cooperation initiatives are best carried out as a joint effort between community employers and providers.     

The impact of managed care enrollment on emergency department use among children with special health care needs

BACKGROUND: Many states recently have experimented with managed care as a way both to control costs and to enhance continuity of care in their publicly financed programs. A few states have applied managed care models to the care of chronically ill children. One marker for the effects of managed care is changes in use of the emergency department (ED). OBJECTIVE: We sought to determine whether a managed care program can reduce ED use for children with chronic health problems. SUBJECTS: We studied chronically ill children who were dually enrolled in Michigan's Title V program for children with special health care needs and Medicaid and who were enrolled in a managed care option at some time during the study period. The managed care model emphasized care coordination and did not include strong financial incentives for utilization and cost control. Sample consisted of 8580 person-months. METHOD: We used a fixed-effect negative binomial Poisson regression model to compare ED use before and after joining a managed care plan to test whether managed care use was associated with reduced likelihood of ED use. RESULTS: Managed care enrollment was associated with a 23% reduction in the incidence of ED use among children dually enrolled in Medicaid and Title V. CONCLUSIONS: A managed care model is associated with statistically significant and substantive reductions in observed use of ED care within an important population of children facing chronic illness.     

Effect of managed care on preventable hospitalization rates in California

BACKGROUND: Hospitalization rates for ambulatory care-sensitive (ACS) conditions have emerged as a potential indicator of health care access and quality. The effect of managed care on reducing these potentially preventable hospitalizations is unknown. OBJECTIVE: To ascertain whether increases in managed care penetration were associated with changes in hospitalization rates for ACS conditions. DESIGN AND SETTING: Longitudinal analysis between 1990 and 1997 of all California hospitalizations for ACS conditions aggregated to 394 small areas. MEASURES: Association of change in ACS hospitalization rate with change in managed care penetration. RESULTS: In unadjusted analysis there was no association between the change in managed care penetration and the change in hospitalization rates for ACS conditions over time. However, in a multivariate model that controlled for changes in area demographics and hospitalization rates for marker conditions that were assumed to be stable over time, the change in managed care penetration was negatively associated with a small but statistically significant change in the ACS hospitalization rate. Each 10-point increase in percentage private managed care penetration was associated with a 3.1% decrease in the ACS hospitalization rate (95% CI, -5.4% to -0.8%) CONCLUSIONS: Overall, in California, an increase in the penetration of private managed care in a community was associated with a decrease in ACS admission rates. Additional research is needed to determine if the observed association is causal, the mechanism of the effect and whether it represents an improvement in patients' health outcomes.     

The effect of screening and brief intervention for risky drinking on health care utilization in managed care organizations

OBJECTIVE: We sought to estimate the effect of screening and brief intervention (SBI) for risky alcohol use on the health care utilization of risky drinkers in 4 managed care organizations. RESEARCH DESIGN: A quasi-experimental group design was implemented in which 12 participating primary care clinics randomly were assigned to 1 of 3 study conditions. In one condition, physicians, physician assistants, and nurse practitioners delivered the brief intervention. In another condition, midlevel professionals (usually nurses) performed the brief intervention. In the third condition, SBI was not performed. Using administrative claims data, we estimated the effect of SBI on individual-level annual days of total and inpatient health care utilization; annual outpatient visits; annual emergency room visits; and annual visits related to alcohol, drug, or mental health conditions. Negative binomial regression models were used to control for other factors that may affect health care utilization. RESULTS: Across all categories of care, the pre- to postintervention change in average health care utilization among risky drinkers in the intervention clinics was not significantly different from that of risky drinkers in the comparison clinics. CONCLUSIONS: Our findings suggest that there is no effect of SBI on the health care utilization of risky drinkers in the year following the intervention. Although SBI does not appear to reduce health care utilization, previous studies find that it significantly reduces the alcohol consumption of risky drinkers. Because these reductions presumably improve patients' overall health and well-being, managed care organizations may still find it beneficial to implement SBI on a broad scale.     

The impact of Medicaid managed care on primary care physician participation in Medicaid

OBJECTIVES: Medicaid managed care has been touted as an important vehicle for increasing physician participation in Medicaid. Although there is anecdotal evidence that the opportunity to participate in Medicaid via managed care increases physician participation, no empirical study has validated the claim. This study explores the relationship between Medicaid managed care penetration at the county-level and the likelihood that a physician practicing in that county will participate in Medicaid. RESEARCH DESIGN: We used 3 waves of a large, nationally representative sample of primary care physicians from the Community Tracking Study followed across time (1996-2001) to estimate the impact of changing Medicaid managed care penetration levels on physician participation in the program. County-level Medicaid managed care penetration rates were collected directly from state Medicaid agencies for the study. FINDINGS: In cross-sectional bivariate and multivariate analyses, Medicaid managed care penetration is significantly associated with physician participation in Medicaid; however, the relationship is nonmonotonic, of small magnitude and generally not in the anticipated direction. Our analyses indicate that a 10 percentage point increase in managed care penetration would reduce the likelihood that physicians participate in Medicaid on average by 2.9 percentage points. Although commercial MCO penetration exhibited a small positive, linear relationship with physician participation, this was not sufficient to offset the effects of Medicaid-dominant MCO penetration. Panel data analysis supported these findings. CONCLUSIONS: This study failed to find that increases in Medicaid managed care lead to increased primary care physician participation in Medicaid during the period 1996-2001.     

Health behaviors among American Indians with spinal cord injury: comparison with data from the 1996 Behavioral Risk Factor Surveillance System

OBJECTIVE: To identify patterns of health behaviors and health outcomes among a sample of American Indian men with spinal cord injury. DESIGN: Telephone interviews with all participants, except those who did not have telephones (they returned materials by mail). SETTING: Large rehabilitation hospital in the Western mountain region of the United States. PARTICIPANTS: Seventy-six American Indian men with traumatic SCI of at least 1 year in duration. MAIN OUTCOME MEASURE: Selected health-related behaviors from the Behavioral Risk Factor Surveillance System (BRFSS) were used to assess health behaviors and general health outcomes among the American Indian SCI sample and to compare findings with those from American Indian men without SCI based on nationwide BRFSS data. RESULTS: The study participants reported lower overall health and satisfaction with health care than the non-SCI BRFSS group. They also reported a different pattern of health behaviors, including a greater frequency of inoculations for flu and pneumonia but a lower rate of HIV testing and cholesterol screening. A smaller percentage of American Indians used alcohol, but those who did reported more heavy drinking. CONCLUSIONS: American Indians with SCI are more likely to receive health care consistent with the prevention of secondary conditions of SCI (eg, pneumonia), but less likely to receive basic health screens intended to prevent chronic health diseases.     

Effect of managed care insurance on the use of preventive care for specific ethnic groups in the United States

BACKGROUND: Ethnic disparities in access to health care is a persistent problem in the US. Despite the broad implementation of managed care, there is little information that specifically addresses how this type of coverage may affect ethnic disparities. OBJECTIVES: To examine the effect of managed care insurance on the use of preventive care for different ethnic groups. RESEARCH DESIGN: Observational cohort using the 1996 Medical Expenditure Panel Survey. SUBJECTS: Adults with health insurance who report their ethnicity as white, black, Hispanic, or Asian/Pacific Islander. MAIN OUTCOME MEASURES: (1) Mammography within the past 2 years for women between 50 and 75 years of age; (2) clinical breast exam within the past 2 years for women between 40 and 75 years; (3) Papanicolaou smear within the past 2 years for women between 18 and 65 years; and (4) cholesterol screening within the past 5 years for men and women older than the age of 20 years. RESULTS: Hispanic people enrolled in a managed care plan report higher rates of mammography, breast exam, and Papanicolaou smear compared with Hispanic people with fee-for-service insurance. For example, the adjusted predicted probability of a mammogram for Hispanic women with managed care was 85.6% compared with 72.4% for Hispanic women with fee-for-service coverage (risk difference: 13.2%; 95% CI for the risk difference 0.7%-25.7%). White persons with managed care are also more likely than white persons with fee-for-service coverage to receive mammography and cholesterol screening. Managed care is not associated with less preventive care for any ethnic group. CONCLUSIONS: In this nationally representative household survey, it was found that managed care is associated with greater use of some preventive care for Hispanic persons and white persons than fee-for-service insurance. Despite a focus on prevention, the benefits of managed care are not apparent for black persons or Asian/Pacific Islanders.