201
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Nauenberg E, Brewer CS. Surveying hospital network structure in New York State: how are they structured? Health Care Manage Rev 2001; 25:67-79. [PMID: 10937338 DOI: 10.1097/00004010-200007000-00008] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
We determine the most common network structures in New York state. The taxonomy employed uses three structural dimensions: integration, complexity, and risk-sharing between organizations. Based on a survey conducted in 1996, the most common type of network (26.4 percent) had medium levels of integration, medium or high levels of complexity, and some risk-sharing. Also common were networks with low levels of integration, low levels of complexity, and no risk-sharing (22.1 percent).
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202
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Garofalo WA. Assessing an IDS's readiness to operate profitably under a risk contract. HEALTHCARE FINANCIAL MANAGEMENT : JOURNAL OF THE HEALTHCARE FINANCIAL MANAGEMENT ASSOCIATION 2001; 55:41-5. [PMID: 11271441] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 02/19/2023]
Abstract
An IDS that wishes to assume risk should understand first the factors that have caused IDSs to experience poor financial performance under risk contracts. Then, the IDS should clarify its goals for managed care contracting, assess its operational strengths and weaknesses, evaluate potential managed care payer partners, and understand the amount of risk associated with various contract options. Implementation issues that need to be addressed include aligning the financial incentives of physicians and the IDS, establishing systemwide policies and procedures for monitoring performance, and developing information systems capabilities.
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203
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Give physicians incentives to deliver value, boost outcomes. CAPITATION MANAGEMENT REPORT 2001; 8:28-30, 17. [PMID: 11234362] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 02/19/2023]
Abstract
The secret of success under capitation for this New England physician group is to pay physicians extra for delivering value. Here's how they determine who gets the money.
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204
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MGMA data reveal higher revenues for heavily capitated groups. CAPITATION MANAGEMENT REPORT 2001; 8:30, 17. [PMID: 11234363] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 02/19/2023]
Abstract
Is there money in capitation? You bet. This Data Insight shows that the multispecialty groups with the highest revenue and charges are those with the greatest percentage of capitation.
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205
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Riley G, Herboldsheimer C. Including hospice in Medicare capitation payments: would it save money? HEALTH CARE FINANCING REVIEW 2001; 23:137-47. [PMID: 12500368 PMCID: PMC4194720] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 12/05/2022]
Abstract
Hospice services received by Medicare risk-based health maintenance organization (HMO) enrollees are paid on a non-capitated basis, creating financial incentives for HMOs to encourage their terminally ill patients to elect hospice. Using Medicare administrative records for 1998, we found that hospice enrollment in the last month of life was significantly higher among HMO enrollees than among beneficiaries in fee-for-service (FFS). However, low mortality rates among HMO enrollees produced similar population-based rates of hospice use in the HMO and FFS sectors. Simulations showed that including hospice care under capitation payments in July 1998 would have produced very small savings for Medicare.
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206
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Harvard Pilgrim's financial distress holds lessons for other risk-bearing groups. CAPITATION MANAGEMENT REPORT 2001; 8:10-3, 1. [PMID: 11209216] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 02/19/2023]
Abstract
What lessons can be learned from the financial collapse and rehabilitation of Harvard Pilgrim Health Plan? One managed care expert says many of the factors that hurt Harvard Pilgrim can be seen in other plans across the nation.
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Abstract
Recently proposed HMO regulations have involved mandates of two forms: (1) minimum quality standards, and (2) mandated increases in access to speciality care. I show that piecemeal regulation, which uses only one of either mandate (1) or (2), may decrease welfare for all HMO consumers. Under full regulation using both (1) and (2), if the minimum standard is set too low, say, due to political bargaining, a floor-to-ceiling effect occurs. This involves HMOs setting quality at the minimum standard, even when their quality would be above the standard in an unregulated market. Finally, I show how premiums may either increase or decrease under a mandate.
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208
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Brewster LR, Ginsburg PB. At the brink: how Harvard Pilgrim got in trouble. ISSUE BRIEF (CENTER FOR STUDYING HEALTH SYSTEM CHANGE) 2000:1-4. [PMID: 11503742] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 02/21/2023]
Abstract
The Massachusetts insurance commissioner placed Harvard Pilgrim Health Care (HPHC) in receivership in January on the basis of large projected losses that put the nonprofit plan in a significant negative net worth position. Because Harvard Pilgrim was the largest health plan in the market, with substantial amounts payable to hospitals and physicians, its financial problems shook the Boston health care community. The story also attracted national attention because of the plan's prominence and its reputation for quality. The Center for Studying Health System Change (HSC) followed the Harvard Pilgrim story closely as part of its continuous tracking of Boston--one of the 12 Community Tracking Study sites visited every two years--and is able to put this event in broader context. Many of Harvard Pilgrim's problems are evident in plans elsewhere. This Issue Brief discusses the causes of the plan's financial problem and the state's response, which has preserved the organization.
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209
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Somers SA, Hurley R, Oehlmann ML. Staying the course: pursuing value in the Medicaid managed care era and beyond. J Urban Health 2000; 77:519-35. [PMID: 11194300 PMCID: PMC3456770 DOI: 10.1007/bf02344021] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
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210
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Use inpatient utilization data to help define risk contract. CAPITATION RATES & DATA 2000; 5:142-4. [PMID: 11147526] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 02/18/2023]
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211
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Use actuarial cost models to allocate global risk. CAPITATION RATES & DATA 2000; 2:59-61. [PMID: 11066336] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 02/18/2023]
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212
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Benchmark data help build your risk contracting strategy. CAPITATION RATES & DATA 2000; 2:14-6. [PMID: 11066322] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 02/18/2023]
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213
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Data on specialty, PCP cap rates suggest wisdom of shared risk. CAPITATION RATES & DATA 2000; 2:17-9. [PMID: 11066323] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 02/18/2023]
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214
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Refine medical management techniques to dramatically reduce utilization rates. CAPITATION RATES & DATA 2000; 2:66-7. [PMID: 11066339] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 02/18/2023]
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215
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Abstract
This paper examines the effects of risk sharing with mental health providers in a managed care context. The results show that providers that received a fixed payment per case reduced the number of outpatient visits by 20-25%, compared with providers who continued to be paid for each visit. This effect was stronger for integrated group practices and providers with more intensive utilization review protocols. In addition, evidence was found that in a setting where providers serve multiple payers, the share of their total revenue derived from risk-sharing contracts is an important determinant of the magnitude of the supply response.
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216
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Chernew M, Cowen ME, Kirking DM, Smith DG, Valenstein P, Fendrick AM. Pharmaceutical cost growth under capitation: a case study. Health Aff (Millwood) 2000; 19:266-76. [PMID: 11192413 DOI: 10.1377/hlthaff.19.6.266] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Rising drug spending has generated concern among purchasers and policymakers. This paper compares drug cost growth in a capitated system with that in managed care systems that generally did not place physicians directly at risk for drug spending. We focus on cost growth because a substantial body of literature indicates that managed care interventions that reduce the level of costs may not influence the rate of cost growth. Drug cost growth under capitation initially was below that of other systems but still above targeted rates. Over time the capitation rates rose, the amount of risk transferred to physicians declined, and spending growth accelerated.
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217
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Beichl L, Berger D. How to identify global markets that are ready for managed care. MANAGED CARE INTERFACE 2000; 13:65-71. [PMID: 11188234] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 02/19/2023]
Abstract
As international risk carriers observe increasing medical loss ratios, many have flocked to managed care in an attempt to control medical costs while allowing for the measurement of care leading to improved quality. These same risk carriers often find it difficult to determine which managed care programs will produce the desired effects. However, it is not always clear why American health care concepts do not always produce the desired results in some international markets.
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218
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Clemmitt M. Perspectives. Medicare drugs and PBMs: a done deal, but still a tale of tradeoffs. MEDICINE & HEALTH (1997) 2000; 54:suppl 1-4. [PMID: 11184141] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 02/19/2023]
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219
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Heffernan JL. The challenges of practice management: an interview with James L. Heffernan. HEALTHCARE FINANCIAL MANAGEMENT : JOURNAL OF THE HEALTHCARE FINANCIAL MANAGEMENT ASSOCIATION 2000; 54:75-8. [PMID: 11183549] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 02/19/2023]
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220
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Phillips VL, Paul W, Becker ER, Osterweil D, Ouslander JG. Health care utilization by old-old long-term care facility residents: how do Medicare fee-for-service and capitation rates compare? J Am Geriatr Soc 2000; 48:1330-6. [PMID: 11037023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/18/2023]
Abstract
OBJECTIVE To describe the healthcare utilization of a long-term care population receiving primary and specialty care in a closed system and to compare Medicare fee-for-service (FFS) reimbursement with the amount that would have been paid under capitation for these services. SETTING A life care community in California composed of two facilities, both having residential care and nursing facility (NF) beds. PARTICIPANTS Residents (n = 700) living in the community between September 1995 and February 1996. METHODS Data on Medicare Part A and Part B reimbursements were gathered from billing records for hospitalizations, based on diagnostic related group payments, primary and specialty care visits, various procedures, diagnostic tests, and therapeutic services. These data were compared with what the facility, in collaboration with the providers and an affiliated hospital, would have received under Medicare capitated rates at that time. RESULTS Annually, residents averaged 16.3 primary care visits, 7.7 specialist visits, and 3453 hospital days per thousand. Nursing facility residents received significantly more primary care than did those in residential care. Total Medicare Part A and B payments per resident per month averaged $558. The monthly capitation rate in effect at the time for this population was substantially higher at $1085, generating an annual "risk pool" of $9.1 million. Care provided in the two facilities varied greatly. Hospitalization rates, clinic-based primary care and specialist visits, and therapy sessions were greater in facility one. Overall expenditures were lower for residents at facility two, where the majority of care was provided by trained geriatricians in collaboration with physician extenders and without sophisticated clinical pathways and utilization controls. CONCLUSIONS Our data support other studies that suggest that teams of geriatricians and physician extenders can reduce hospitalization rates and overall expenditures. Capitated rates for the frail, geriatric population warrant careful study. These rates must balance fiscal responsibility with the need for adequate, risk-adjusted payments that create incentives for providers to produce high quality as well as cost-effective care.
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221
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Schraeder C, Britt T, Shelton P. Integrated risk assessment and feedback reporting for clinical decision making in a Medicare Risk plan. J Ambul Care Manage 2000; 23:40-7. [PMID: 11067092 DOI: 10.1097/00004479-200010000-00006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
The challenge of tapping into the rich resource of population-based, aggregated data to inform and guide clinical processes remains one of the largely unrealized potentials of managed care. This article describes a multifaceted approach of using health-related data to support providers in clinical decision making as an adjunct to case management and primary care delivery. The goal is to provide data that can be used for clinical decision making that is population based, yet individualized for specific patient care situations. Information reporting holds great potential in the clinical care of patients because it can be used to identify persons who could benefit from early detection, intervention, or treatment. It has been suggested that one of the keys to success in managed Medicare is the timely use of information that is detailed, comprehensive, and real-time describing key parameters of clinical encounters.
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222
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Sturm R. How does risk sharing between employers and a managed behavioral health organization affect mental health care? Health Serv Res 2000; 35:761-76. [PMID: 11055447 PMCID: PMC1089151] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/18/2023] Open
Abstract
OBJECTIVE To study the ways in which allocating the risk for behavioral health care expenses between employers and a managed behavioral health organization affects costs and the use of services. DATA SOURCES Claims from 87 plans that cover mental health and substance abuse services covering over one million member years in 1996/1997. STUDY DESIGN Multi-part regression models for health care cost are used. Dependent variables are health care costs decomposed into access to any care, costs per user, any inpatient use, costs per outpatient user, and costs per inpatient user. The study compares full-risk plans, in which the managed care organization provides managed care services and acts as the insurer by assuming the risk for claims costs, with contracts in which the managed care organization only manages care (for a fixed administrative fee) and the employer retains the risk for claims. PRINCIPAL FINDINGS Full-risk plans are not statistically significantly different from non-risk plans in terms of any mental health specialty use or hospitalization rates, but costs per user are significantly lower, in particular for inpatients. CONCLUSIONS Risk contracts do not affect initial access to mental health specialty care or hospitalization rates, but patients in risk contracts have lower costs, either because of lower intensity of care or because they are treated by less expensive providers.
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223
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Martin ND. Funding long-term care: some risk-spreaders create more risks than they cure. THE JOURNAL OF CONTEMPORARY HEALTH LAW AND POLICY 2000; 16:355-86. [PMID: 10921233] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 02/17/2023]
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224
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Conviser R, Murray M, Lau D. Medicaid managed care reimbursement for HIV and its implications for access to care. THE AMERICAN JOURNAL OF MANAGED CARE 2000; 6:990-9. [PMID: 11184069] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 02/19/2023]
Abstract
The rapid growth of managed care in state Medicaid programs has raised concerns about access to care for people living with HIV and AIDS (PLWH). Even the highest capitation rates that most programs pay to managed care organizations (MCOs) for disabled enrollees are substantially lower than the costs of care, especially when costly protease inhibitor therapy is taken into account. A national study has shown that Medicaid beneficiaries did not have the same level of access to protease inhibitors as did privately insured HIV patients in 1996 and 1997. Low capitation rates can limit access to care for PLWH by discouraging MCOs from having experienced HIV physicians on their provider panels and from enrolling PLWH. Since 1997, however, Medicaid programs in several states have adopted strategies to reduce the financial risks facing MCOs caring for PLWH and enrollees with other high-cost conditions. These strategies include global health-based (risk-adjusted) payment systems, AIDS-specific reimbursement rates, carve outs from capitation rates for medications and other services, risk pools for high-cost enrollees, risk corridors, and stop-loss insurance policies through which Medicaid programs share financial liability with MCOs for catastrophic losses. In addition, several programs have developed HIV centers of excellence. Most state Medicaid programs have yet to adopt any of these strategies. However, the growing numbers and types of experimental approaches to capitating services for PLWH may provide models for other states whose low reimbursement rates currently limit access to care.
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225
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Stick with capitation? For many, the answer is yes. CAPITATION MANAGEMENT REPORT 2000; 7:129-33. [PMID: 11186339] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 02/19/2023]
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226
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Benoff M, Harris JM. IDSs reconsider the viability of risk contracting. HEALTHCARE FINANCIAL MANAGEMENT : JOURNAL OF THE HEALTHCARE FINANCIAL MANAGEMENT ASSOCIATION 2000; 54:35-9. [PMID: 11066386] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 02/18/2023]
Abstract
As financial success with risk contracting continues to elude many IDSs, some of these organizations have started questioning their overall mission as risk-bearing entities. To determine whether to continue to assume risk, an IDS should consider its market environment, the commitment of its provider constituents to the organization, its core competencies, the likelihood of success with risk contracting, and alternatives. To determine its future course, the IDS should engage in a strategic-planning process that includes all IDS stakeholders. Such a process can help build consensus regarding the IDS's market characteristics and benefits of IDS membership; determine the IDS's appropriate roles, services, and functions; and evaluate resources required to pursue the desired strategy. The process should include planning for various possible future scenarios, and results should be communicated to all IDS provider constituents.
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227
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Tool helps ID high-risk seniors, cut costs under Medicare risk. CAPITATION MANAGEMENT REPORT 2000; 7:137-40, 129. [PMID: 11186343] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 02/19/2023]
Abstract
Health risk evaluation surveys can help physician groups with Medicare risk contracts identify problem patients, curtail costs, and boost profits. Here's how you can adapt this tool in your organization.
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228
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Underfunded contracts wreak havoc with the promise of contact capitation. CAPITATION MANAGEMENT REPORT 2000; 7:133-5, 129. [PMID: 11186340] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 02/19/2023]
Abstract
Once a favored technique for specialists, contact capitation has fallen out of favor, primarily because there isn't enough money going to physicians. Here's how to make contact capitation work.
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229
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Review cost, utilization data to project risk for DM programs. CAPITATION RATES & DATA 2000; 5:93-6. [PMID: 11186739] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 02/19/2023]
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230
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McLean RA, Magiera FT. Options analysis of managed care contracting and regulation: theory and evidence. Health Serv Manage Res 2000; 13:170-7. [PMID: 11184019 DOI: 10.1177/095148480001300305] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Managed care contracts can be represented as bundles of options. In particular, the managed care provider is short a call option. To hedge the risk involved in such contracts, managed care contractors can construct several types of virtual put options, among them the ownership of facilities. Agency theory and options theory suggest that for-profit managed care plans, in the presence of debt, will engage in less hedging activity than will other managed care plans. Here, the authors test that hypothesis, using data for Florida HMOs in 1995, and they reject the null hypothesis. That managed care organizations act as if they are short a call option raises interesting regulatory issues, including the possibility of using a hedge-based regulatory scheme in place of a net-worth-based scheme.
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231
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Use your own data to establish cost, utilization benchmarks. CAPITATION RATES & DATA 2000; 5:87-9. [PMID: 11186736] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 02/19/2023]
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232
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Physician group flourishes after dropping Medicare FFS. CAPITATION MANAGEMENT REPORT 2000; 7:116-7. [PMID: 11186756] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 02/19/2023]
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233
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What happens when providers don't understand plan contracts? DATA STRATEGIES & BENCHMARKS : THE MONTHLY ADVISORY FOR HEALTH CARE EXECUTIVES 2000; 4:119-21. [PMID: 11186770] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 02/19/2023]
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234
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235
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Bennett AH. Finding success in a capitated environment. FAMILY PRACTICE MANAGEMENT 2000; 7:49-53. [PMID: 11010610] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 02/17/2023]
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236
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Boland P. Medical group bankruptcies: an emerging problem. THE JOURNAL OF MEDICAL PRACTICE MANAGEMENT : MPM 2000; 16:19-21. [PMID: 14608764] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 04/27/2023]
Abstract
This article explores the reasons why medical group practices and independent practice associations are filing for bankruptcy with increasing frequency. The problem stems from capitation payments by managed care organizations that are not sufficient to cover the costs of providing necessary care. The result is the dislocation of patients who have to find a new provider and providers who have to find a new practice setting. This article suggests that if the managed care industry could adopt clinical risk adjustment as a mainstay of physician compensation, medical groups and IPAs would have a far better chance of managing patient risk more successfully under capitation.
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237
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Get providers the data they need to manage risk successfully. CAPITATION MANAGEMENT REPORT 2000; 7:105-9. [PMID: 11067409] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 02/18/2023]
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238
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Carroll J. Physicians reconsider taking on pharmacy risk. MANAGED CARE (LANGHORNE, PA.) 2000; 9:37-43. [PMID: 18540340] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/26/2023]
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239
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Maniccia MD. Fixing responsibility for risk management. MEDICAL GROUP MANAGEMENT JOURNAL 2000; 47:26-33. [PMID: 11010506] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 02/17/2023]
Abstract
The responsibility for carrying financial risk for medical coverage has migrated from individuals to insurers to employers to providers, without finding a satisfactory home. Each shift further complicates the health care infrastructure, as other responsibilities in the management of benefits and provision of care gravitate to the stakeholder who accepts risk. The social imperative to broaden coverage is forcing a change in the mechanisms of risk management--from avoiding high-risk patients, to managing those patients to better outcomes. In this paper we seek to identify objectively the most appropriate party to carry the financial risk of medical coverage, consider what characteristics are necessary to make that a practical and enduring solution, and examine the secondary effects of the structure required to support that solution.
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240
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Ritterband DR. Disease management: old wine in new bottles? J Healthc Manag 2000; 45:255-66. [PMID: 11067417] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/18/2023]
Abstract
Disease management is a holistic, patient-focused approach to the treatment of disease across the spectrum of healthcare delivery. In its current form, disease management was created in response to the societal and economic burden that chronic illness contributes. There has recently been rapid growth in the development of disease management programs and sponsors are widespread within the industry, with the largest increase in independent vendors. Although growth has been substantial, the hurdles these programs have encountered have kept them from reaching their full potential. The challenges that exist include clinical, financial, and regulatory issues, and these challenges have significant meaning to healthcare managers. In deciding whether to develop or enhance programs, executives must consider their capability of outcomes measurement, their provider relationships, and the arrangements for program implementation. Ultimately, if programs provide improved health and quality of life for participants, cost savings will follow.
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241
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Evidence-based medicine helps providers offer cost-effective care. CAPITATION MANAGEMENT REPORT 2000; 7:88-90. [PMID: 11067404] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 04/15/2023]
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242
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Study shows increases in drug costs may be justified by improvements in outcomes. CAPITATION RATES & DATA 2000; 5:65-8. [PMID: 11067438] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 04/15/2023]
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243
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Farley DE. Achieving a balance between risk and return. HEALTHCARE FINANCIAL MANAGEMENT : JOURNAL OF THE HEALTHCARE FINANCIAL MANAGEMENT ASSOCIATION 2000; 54:54-8. [PMID: 11010183] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 02/17/2023]
Abstract
Because risk management is costly, many health plans and providers practice risk avoidance by transferring risk to other entities. Risk-bearing healthcare organizations can improve their return on assets, but to do so they need complete information about patients' health status and the availability of effective medical treatment. To improve their return on assets, providers can use risk-management strategies such as growth, designing incentives to encourage providers and health plans to reduce or eliminate unnecessary variations in resource use, and improving information about the reasons for variations in resource use and controlling those variations when possible. Providers need data to analyze why variations in resource use occur and to evaluate the efficiency of their resource use.
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244
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A textbook example of how to fail at risk contracting. CAPITATION MANAGEMENT REPORT 2000; 7:81-4. [PMID: 11067402] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 02/18/2023]
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245
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Benko LB. Rolling the dice in the Big Apple. MODERN HEALTHCARE 2000; 30:3, 10. [PMID: 11067158] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 02/18/2023]
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Bazzoli GJ, Miller RH, Burns LR. Capitated contracting roles and relationships in healthcare. J Healthc Manag 2000; 45:170-87; discussion 187-8. [PMID: 11066966] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/18/2023]
Abstract
Capitated contracting of health providers has created substantial change in healthcare markets. This article assesses how capitation affects the roles and relationships of healthcare organizations. In-depth case studies were conducted of eight major hospital-led integrated health networks/systems and two large integrated medical groups. Types of capitated contracts employed, contract support capabilities developed, relationships among providers in the support services, and lessons learned about capitation were explored. The experiences of these organizations provide valuable guidance for health executives as they develop or refine capitated contracting strategies.
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Herrick M, Patterson A. Healthcare trends--the big picture. Megatrends you need to know about. JOURNAL OF AHIMA 2000; 71:26-31; quiz 33-4. [PMID: 11009871] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 02/17/2023]
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Use this checklist to assess your readiness for risk. CAPITATION MANAGEMENT REPORT 2000; 7:73-4. [PMID: 11066944] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 02/18/2023]
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Use these data to maximize your contribution margins. CAPITATION MANAGEMENT REPORT 2000; 7:75-7. [PMID: 11066945] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 02/18/2023]
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Broskowski A. Systemic impact of risk-sharing arrangements. NEW DIRECTIONS FOR MENTAL HEALTH SERVICES 2000:113-8. [PMID: 10758726 DOI: 10.1002/yd.23320008515] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
The overall complexity and systemic impact of what is ostensibly a simple change in payment methods were the most important lessons to learn.
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