Change and growth in managed care

Satisfaction with the level and type of resource use of a health insurance scheme in Nigeria: health management organizations' perspectives

Some developing countries have incorporated managed care elements into their national health insurance schemes. In practice, hybrid health management organizations (Hmos) are insurers who, bearing some resemblance to managed care in the USA, are vertically integrated in the scheme's revenue collection and pool and purchase healthcare services within a competitive framework. To date, few studies have focused on these organizations and their level of satisfaction with the scheme's optimal-resource-use (ORU) implementation. In Nigeria, the study site, Hmos were categorized on the basis of their satisfaction with ORU activities. One hundred forty-seven Hmo staff were randomly interviewed. The types of ORU domain categories were provider payment mechanism, administrative efficiency, benefit package inclusions and active monitoring mechanism. Bivariate analysis was used to determine differences among the Hmos' satisfaction with the various ORU domains. The Hmos' satisfaction with the health insurance scheme's ORU activities was 59.2% generally, and the associated factors were identified. According to the Hmos' perspectives related to the type of ORU, the fee-for-service payment method and regular inspection performed weakly. Hmos' limited satisfaction with the scheme's ORU raises concerns regarding ineffectiveness that may hinder implementation. To offset high risks in the scheme, it appears necessary for the regulatory agency to adapt and reform strategies of provider payment and active monitoring mechanisms according to stakeholder needs. Our findings further reveal that having Hmos evaluate ORU is useful for providing evidence-based information for policy making and regulatory utilization related to implementation of the health insurance scheme.

Managed care regulation in the States: the impact on physicians' practices and clinical autonomy

While the states engaged in an extended period of adopting and revising laws regulating managed care during the 1990s, there has been to date only limited empirical assessment of the impacts of these laws. For this analysis, we constructed a data set using information on state laws combined with survey responses of physicians. We distinguish regulations with a typology based on whether they affect the context or content of care and the target group of the regulation (consumer or provider). Our findings indicate that the context of care appears to be more efficaciously regulated than the content of care. Provisions concerning consumer access and contractual relationships lead to greater reported physician ability to obtain referrals and services, improved quality of clinical interactions, and greater perceived clinical autonomy. Regulations intended to enhance professional autonomy are associated with lower reported levels of utilization constraints and higher reported quality of clinical interactions. In contrast, consumer protection provisions, including procedures for appeals from plan decisions, appear to have had little impact on most physicians' practices. Despite structural and legal constraints on the potential effectiveness of these regulations, state managed care legislation appears to have provided some protections against managed care restrictions on physicians' clinical autonomy.

Clinicians as advocates: an exploratory study of responses to managed care by mental health professionals

Utilization review and other managed care techniques require that health care professionals assume new responsibilities as patient advocates. This article explores the extent to which characteristics of providers or their experiences with managed care practices predict the nature and extent of advocacy behavior. Interviews of 142 mental health providers revealed that experiences of harmful utilization review and norms of professionalism significantly predicted advocacy behavior. However, providers who were concerned about disaffiliation were less likely to challenge the plan directly but more likely to alter their presentation of the case to reviewers. Providers who believe that managed care plans retaliate against advocacy behavior appear to substitute covert advocacy for direct advocacy. These results are preliminary but suggest that providers condition their advocacy behavior in response to their experiences with and perceptions of managed care plans.

Financing of substance abuse treatment services

The financing of treatment for substance abuse problems has differed from the rest of financing of health care in part because of the dominant role of the public sector as the payer of services. Nonetheless, the rise of managed care has affected substance abuse treatment services as well as the rest of the health care system. Alternative payment mechanisms are one important component of some managed care approaches. Behavioral health carve-outs are another managed care development that has affected substance abuse services. In this chapter, salient features of financing for substance abuse treatment are reviewed within the conceptual framework of payers (purchasers and intermediaries), providers, and consumers. Existing literature on substance abuse treatment financing is summarized, while recognizing that much remains to be researched.

Not afraid to blame: the neglected role of blame attribution in medical consumerism and some implications for health policy

A crucial aspect of medical consumerism has been overlooked in past research and policymaking: how consumers decide whom to "blame" for bad outcomes. This study explores how, in a system increasingly dominated by managed care, these attributions affect consumers' attitudes and behavior. Using data from the experiences of people with serious mental illness, hypotheses are tested regarding the origins and consequences of blaming for medical consumerism. Blame was allocated to health plans in a manner similar, but not identical, to the way in which blame was allocated to health care professionals. Both allocations are shaped by enrollment in managed care, with blame allocation affecting consumers' subsequent willingness to talk about adverse events. Policy implications include the need for more finely tuned grievance procedures and better consumer education about managed care practices.

Wrestling with typology: penetrating the "black box" of managed care by focusing on health care system characteristics

The health care system has undergone a fundamental transformation undermining the usefulness of the typology of the health maintenance organization, the independent practice association, the preferred provider organization, and so forth. The authors present a new approach to studying the health care system. In matrix form, they have identified a set of organizational and delivery characteristics with the potential to influence outcomes of interest, such as access to services, quality, health status and functioning, and cost. The matrix groups the characteristics by domain--financial features, structure, care delivery and management policies, and products--and by key roles in the health care system--sponsor, plan, provider intermediary organization, and direct services provider. The matrix is a tool for researchers, administrators, clinicians, data collectors, regulators, and other policy makers. It suggests a new set of players to be studied, emphasizes the relationships among the players, and provides a checklist of independent, control, and interactive variables to be included in analyses.

Managed care and its implications for social work curricula reform: clinical practice and field instruction

Managed care continues to be a major focus and debate within the health care field. Regardless of whether one is for or against managed care, it has become the predominant system for distributing finite health care resources. Many academicians and practitioners point to the uncertainty about the future of health care, and the role of social workers to practice within these new environments, schools of social work will need to integrate content related to managed care. Students should be exposed to a more balanced analysis of what is advantageous and problematic with managed care. This paper offers recommendations regarding ways in which the practice and field curriculum can be strengthened to more effectively prepare social workers for practice within a managed care environment.

Does managing behavioral health care services increase the cost of providing medical care?

This study examined the possibility that managing behavioral health care services achieves savings by cost shifting--by denying care or impeding access to care--and in that way encouraging patients to seek needed behavioral health care in the medical care system. In 1993, a large industrial company carved out employee behavioral health care from its unmanaged, indemnity medical care benefits and offered employees an enhanced benefit package through a managed behavioral health care company. This study compared the use and cost of behavioral health care and medical care services for two years before the carve-out and for three years afterward. The rate of behavioral health care usage remained the same or increased after the carve-out, while the cost of providing the care decreased. Controlling for trends that began before the inception of managed behavioral health, medical care costs decreased for those using behavioral health care services. No evidence supporting cost shifting was found.

Targets and systems of health care cost control

Discussion of health care cost control policy and politics tends to focus on terms such as "market," "government," and "managed care" that are either too general or too value laden to encourage sound analysis. This article proposes an alternative framework for classifying cost control policies. It first distinguishes targets from systems of control. Targets can then be divided into categories of service (e.g., hospital care, pharmaceutical treatment) and components of cost (e.g., price and volume). Systems can be classified in terms of the degree of pooling of finance, ranging from no insurance to a single pool of funds, and how payment of providers is organized, ranging from all payers paying all providers on the same terms to extensive selective contracting among payers and providers. The article analyzes examples of target policy and politics, system policy and politics, and how system choices can influence which targets are targeted how well, so as to show that both policy consequences and political alignments become clearer by using these terms. As one instance, discussions of "managed care" are often confused because the term has two meanings, one referring to target policy and one to system policy.

Determinants of managed care penetration

This paper examines factors associated with differences in managed care penetration across geographic areas. Two alternative measures of managed care penetration are considered: the percentage of revenue physicians received from managed care contracts and market survey data on enrollments in managed care plans. Results are similar for both types of measures. Our analysis suggests that demographics, labor market characteristics and supply side variables including the level of concentration in hospital markets, hospital occupancy rates and the practice organization patterns of physicians are all important determinants of managed care penetration.

The current health care environment and stages of market development

The history of medical payment strategies is reviewed with a historical perspective on the development of the health care system in the United States. The growth of managed care is discussed with sections detailing the effects on and responses of health care providers, the insurance industry, government, consumers, and employers. Current status and future market trends are discussed.

Resource utilization control processes as indicators of quality in managed care organizations: a proposal

Central to the development of a competitive market for managed care products is the ability to measure the quality of care provided by individual managed care organizations (MCOs). Several types of quality measures could be considered for this purpose: patient and provider satisfaction, a listing of specific services provided to patients, or clinical outcomes of such services. Although assessing quality with measures of the process of care is commonplace, we propose developing measures of the production processes that control utilization of health care resources within an organization. Evaluation of these production or resource utilization control processes, although not a substitute for health outcomes assessment, may improve our knowledge of the delivery of services within managed care organizations. We present a paradigm for evaluation of health care resource utilization control processes within managed care organizations based on our description of internal and external controls for health care resource management. This paradigm can serve as a framework for further research into the quality of care provided by these organizations and the processes of health care resource management in MCOs.

Effect of a nurse case manager on postdischarge follow-up

OBJECTIVE

To examine whether use of a nurse case manager to coordinate postdischarge care would improve rates of follow-up, emergency department utilization, and unexpected readmission for general medicine patients.

DESIGN

Prospective cohort trial.

SETTING

Publicly supported, tertiary-care teaching hospital.

PATIENTS

Four hundred seventy-eight patients admitted to the general medicine service.

INTERVENTIONS

Use of a nurse case manager to provide discharge planning before hospital discharge and to arrange for postdischarge outpatient follow-up. Patients in the control group had discharge planning in the traditional ("usual care") manner.

MEASUREMENTS AND MAIN RESULTS

The proportion of patients with scheduled outpatient appointments in the medical clinic and the proportion making clinic visits, emergency department visits, or with readmission to the hospital within 30 days following discharge. A significantly greater proportion of patients assigned to the nurse case manager intervention had appointments scheduled at the time of hospital discharge (63% vs 46%, p < .001), and made scheduled visits in the outpatient clinic (32% vs 23%, p < .03). Intervention group patients were especially more likely than control group patients to have definite follow-up appointments if they were discharged on weekends. Intervention and control group patients did not differ, however, in the rates of emergency department utilization (p = .52) or unexpected readmissions within 30 days of discharge (p = .11).

CONCLUSIONS

Use of a nurse case manager to coordinate outpatient follow-up prior to discharge improved the continuity of outpatient care for patients on a general medical service. The intervention had no effect on unexpected readmissions or emergency department utilization.

[Current models in health insurance and health care delivery]

Health care organizations similar to American HMOs have recently appeared in Switzerland. They elicit many reactions, both in the general public and among the medical profession. In contrast to traditional health insurance, HMOs organize and actively manage health care delivered to their members. This paper reviews the historical background of similar organizations in Europe and in the United States, and focuses in particular on the recent evolution and fragmentation of the concept of "managed care". Follows a discussion of the mechanisms and the side-effects of various tools used to manage care, both in managed care settings and by traditional health insurance plans. It appears that all of health care is managed, that all management tools have potential side effects, and that use of some management tools implies a redistribution of the respective roles of plan members, administrators, and physicians. The authors suggest that the complexity of health care management requires a more active implication of the health professions in that process.

Charity and community: the role of nonprofit ownership in a managed health care system

As American medicine has been transformed by the growth of managed care, so too have questions about the appropriate role of nonprofit ownership in the health care system. The standards for community benefit that are increasingly applied to nonprofit hospitals are, at best, only partially relevant to expectations for nonprofit managed care plans. Can we expect nonprofit ownership to substantially affect the behavior of an increasingly competitive managed care industry dealing with insured populations? Drawing from historical interpretations of tax exemption in health care and from the theoretical literature on the implications of ownership for organizational behavior, we identify five forms of community benefit that might be associated with nonprofit forms of managed care. Using data from a national survey of firms providing third-party utilization review services in 1993, we test for ownership-related differences in these five dimensions. Nonprofit utilization review firms generally provide more public goods, such as information dissemination, and are more "community oriented" than proprietary firms, but they are not distinguishable from their for-profit counterparts in addressing the implications of medical quality or the cost of the review process. However, a subgroup of nonprofit review organizations with medical origins are more likely to address quality issues than are either for-profit firms or other nonprofit agencies. Evidence on responses to information asymmetries is mixed but suggests that some ownership related differences exist. The term "charitable" is thus capable of a definition far broader than merely the relief of the poor. While it is true that in the past Congress and the federal courts have conditioned the hospital's charitable status on the level of free or below cost care that it provided for indigents, there is no authority for the conclusion that the determination of "charitable" status was always so limited. Such an inflexible construction fails to recognize the changing economic, social and technological precepts and values of contemporary society. -Circuit Court of Appeals, District of Columbia, Eastern Kentucky Welfare Rights Organization v. Simon (1974).

Behind the curve: a critical assessment of how little is known about arrangements between managed care plans and physicians

Extraordinary growth in managed care arrangements over the past decade has been both widely praised and criticized. Proponents and critics agree that the nature of medical practice is being profoundly altered by this growth, even if they cannot articulate the direction and consequences of this change. We explore the roots of this uncertainty by examining the available evidence on critical features of the arrangements managed care plans currently have with affiliated physicians. Our approach is to review and synthesize the literature in several key substantive areas from a broad range of sources. We found that existing knowledge is dated, derived form a limited subset of plans, inattentive to important structural differences between plans, and responsive to a very narrow set of issues poorly reflecting the range of medical practice and change introduced by managed care. We highlight key questions of interest and the knowledge gaps critical to address so that policy and management decisions can both reflect and be informed on these issues that define the arrangements managed care plans make with physicians and ultimately influence medical practice.

Depression in general medical settings. Implications of three health policy studies for consultation-liaison psychiatry

Prepaid or prospective reimbursement has implications for the consultation-liaison (C-L) psychiatrist. The author reviews results from three health policy studies that indicated 1) degree of reliance on general medical providers for mental health care is not affected by generosity of fee-for-service (FFS) coverage, but is greater in some prepaid health care systems; 2) psychological sickness of depressed outpatients visiting general medical providers is similar across prepaid and FFS systems of care; 3) prepaid care is associated with lower rates of detection of depression and counseling in the general medical sector; 4) depression outcomes in the general medical sector are similar under prepaid or FFS care; 5) quality of care for depressed patients is moderate to low in the general medical sector; and 6) depressed elderly inpatients receive higher quality of psychological care in psychiatric units, but they receive higher quality of physical care in general medical wards. The discussion emphasizes the C-L psychiatrist's role in educating general medical providers, improving outcomes for the sickest patients, and improving psychosocial care in prepaid practices.

Potential impact of managed care on national health spending

Illustrative estimates suggest that if all acute health care services were delivered through staff- or group-model health maintenance organizations (HMOs), national health spending might be almost 10 percent lower. If the delivery of all such services (except those now provided by staff- or group-model HMOs) were subject to utilization review arrangements incorporating precertification and concurrent review of inpatient care, spending might be 1 percent lower. The estimates assume no changes in the health care system apart from expansion of these two forms of managed care to cover all insured persons. They also assume that moving to universal managed care would produce a one-time drop in the level of national health spending with no subsequent effect on spending growth.

Income-related cost sharing in health insurance

The vast majority of health plans in the United States require patients to meet cost-sharing requirements that are unrelated to income. Because this is highly inequitable, the authors propose a new system in which cost sharing is explicitly linked to income levels. This proposal differs from earlier proposals to relate cost sharing to income, which relied on the federal income tax system. In this plan, employers and insurers (both public and private) would collect the information necessary to relate cost sharing amounts to income. The proposal could be applied to nearly any health system reform proposal currently under discussion. The authors examine the experience of a number of U.S. firms that have already incorporated income-related cost sharing, as possible models to apply to health insurance nationwide.

Razing a Tower of Babel: a taxonomy for managed care and health insurance plans

To many, the U.S. health care system has become an unintelligible alphabet soup of three-letter health plans. There is little agreement about which characteristics distinguish one type of plan from another. In this article we chip away at what has become a Tower of Babel of managed care and health insurance terminology. We review past and current trends in the market for nontraditional health benefit plans and propose a taxonomy, or system of classification, that will aid in understanding how managed care plans differ from conventional health insurance and from one another. Also included is a comprehensive glossary of terms.

Problems with expanding Medicaid for the uninsured

Many proposals for financing health care for the uninsured recommend expanding the Medicaid program. They often advocate extending Medicaid to all those under the poverty level and standardizing program benefits. However, the proposals have ignored important problems that must be resolved if the plans are to be successfully implemented, the most serious being the fiscal impacts that such proposals would have on states. The current Medicaid matching formula fails to reflect either the size of a state's Medicaid program or its ability to pay for it. As a result, the proportional fiscal effort that expansion proposals would require of states would greatly exceed that required of the federal government. Additionally, the fiscal impact would vary widely and have little relationship to a state's current Medicaid program generosity. Besides fiscal problems, significant differences exist between Medicaid and private plans in the areas of benefits, cost sharing, managed care, cost containment, and provider payment. Under a national system of health care, these differences would limit program economies, and create problems with perceived equity, continuity of care, and migration effects.