-
Journal of Managed Care & Specialty... Apr 2020To review the development and implementation of prescription formularies by managed care organizations, identify their current applications, and recognize future trends... (Review)
Review
To review the development and implementation of prescription formularies by managed care organizations, identify their current applications, and recognize future trends in the managed care pharmacy environment. Current journal articles and texts regarding the use of formularies and the managed care environment. Not applicable. Formulary systems have proven to be a valuable means to control the pharmacy benefit and can be expected to expand in both scope and sophistication.
Topics: Formularies as Topic; Health Plan Implementation; History, 20th Century; History, 21st Century; Managed Care Programs; Pharmacy Service, Hospital; Pharmacy and Therapeutics Committee
PubMed: 32223609
DOI: 10.18553/jmcp.2020.26.4.341a -
Journal of Managed Care & Specialty... Nov 2020Managed care pharmacy has a relatively short history, but one that is defined by significant achievements. Since the late 1960s, managed care pharmacists have applied...
Managed care pharmacy has a relatively short history, but one that is defined by significant achievements. Since the late 1960s, managed care pharmacists have applied their unique skills to formulary management, clinical programs, benefit design, and contract negotiations to support patient access to life-saving therapies, while also ensuring cost-effective use of limited health care resources. Key milestones include establishing the pharmacy benefit as an essential component of the U.S. health care system, launching the Medicare Part D program, and expanding medication therapy management services. The year 2020 brings another milestone-the 25th anniversary of AMCP's flagship publication, the This year also serves as an inflection point. As managed care pharmacy professionals prepare for change and the challenges ahead-including the imperative to address the rising costs of health care and health disparities-the use of evidence, utilization management strategies, and innovation will support our continued success. No funding supported the writing of this commentary. The authors have nothing to disclose.
Topics: Anniversaries and Special Events; Drug Costs; Forecasting; History, 20th Century; History, 21st Century; Humans; Managed Care Programs; Medicare Part D; Medication Therapy Management; Periodicals as Topic; Pharmaceutical Services; United States
PubMed: 33119449
DOI: 10.18553/jmcp.2020.26.11.1379 -
Annual Review of Public Health Apr 2020Medicaid is integral to public health because it insures one in five Americans and half of the nation's births. Nearly two-thirds of all Medicaid recipients are... (Comparative Study)
Comparative Study Review
Medicaid is integral to public health because it insures one in five Americans and half of the nation's births. Nearly two-thirds of all Medicaid recipients are currently enrolled in a health maintenance organization (HMO). Proponents of HMOs argue that they can lower costs while maintaining access and quality. We critically reviewed 32 studies on Medicaid managed care (2011-2019). Authors reported state-specific cost savings and instances of increased access or quality with implementation or redesign of Medicaid managed-care programs. Studies on high-risk populations (e.g., disabled) found improvements in quality specific to a state or a high-risk population. A unique model of managed care (i.e., the Oregon Health Plan) was associated with reduced costs and improved access and quality, but results varied by comparison state. New trends in the literature focused on analysis of auto-assignment algorithms, provider networks, and plan quality. More analysis of costs jointly with access/quality is needed, as is research on managing long-term care among elderly and disabled Medicaid recipients.
Topics: Cost Savings; Health Maintenance Organizations; Health Services Accessibility; Humans; Managed Care Programs; Medicaid; Quality of Health Care; United States
PubMed: 32237985
DOI: 10.1146/annurev-publhealth-040119-094345 -
Journal of General Internal Medicine Feb 1999
Review
Topics: Female; Humans; Male; Managed Care Programs; Quality of Health Care; United States
PubMed: 10051786
DOI: 10.1046/j.1525-1497.1999.00299.x -
Cancer Mar 2011It is important to maintain high-quality cancer care while reducing spending. This requires an understanding of how stakeholders define "quality." The objective of this... (Review)
Review
BACKGROUND
It is important to maintain high-quality cancer care while reducing spending. This requires an understanding of how stakeholders define "quality." The objective of this literature review was to understand the perceptions patients, physicians, and managed care professionals have about quality cancer care, especially chemotherapy.
METHODS
A computerized literature search was conducted for articles concerning quality cancer care in patients who received chemotherapy. Among >1100 identified sources, 25 presented interviews/survey results from stakeholders.
RESULTS
Patients defined quality cancer care as being treated well by providers, having multiple treatment options, and being part of the decision-making process. Waiting to see providers, having problems with referrals, going to different locations for treatment, experiencing billing inaccuracies, and navigating managed care reimbursement negatively affected patients' quality-of-care perceptions. Providers perceived quality cancer care as making decisions based on the risks-benefits of specific chemotherapy regimens and patients' health status rather than costs. Providers objected to spending substantial time interacting with payers instead of delivering care to patients. Payers must control the costs of cancer care but do not want an adversarial relationship with providers and patients. Payers' methods of managing cancer more efficiently involved working with providers to develop assessment and decision-assist tools.
CONCLUSIONS
Delivering quality cancer care is increasingly difficult because of the shortage of oncologists and rising costs of chemotherapy agents, radiation therapy, and imaging tests. The definition of quality cancer care differed among stakeholders, and healthcare reform must reflect these various needs to maintain and improve quality while controlling costs.
Topics: Algorithms; Antineoplastic Combined Chemotherapy Protocols; Attitude to Health; Humans; Managed Care Programs; Neoplasms; Perception; Quality of Health Care
PubMed: 20939015
DOI: 10.1002/cncr.25644 -
The Journal of Thoracic and... Oct 1997
Topics: Cost Control; Ethics, Medical; Humans; Managed Care Programs
PubMed: 9338636
DOI: 10.1016/S0022-5223(97)70039-4 -
Public Health Reports (Washington, D.C.... 1997Managed care is fast becoming the dominant form of medical care delivery and financing in the United States, yet its effects on public health practice remain largely... (Review)
Review
Managed care is fast becoming the dominant form of medical care delivery and financing in the United States, yet its effects on public health practice remain largely unknown. Tuberculosis (TB) is a classic example of a disease with both public health and medical care implications, and as such it provides an opportunity for examining the impact on public health of the shift towards managed care in the medical marketplace. The authors approach the role of managed care in TB control by first considering the need for interorganizational coordination at the community level. The authors identify four basic models of how managed care organizations may fit into TB control efforts in local communities, using observations from 12 local public health jurisdictions to illustrate these models. These TB control models provide insight into the general mechanisms through which managed care organizations may affect other areas of public health practice.
Topics: Centers for Disease Control and Prevention, U.S.; Financial Management; Health Services Needs and Demand; Humans; Interinstitutional Relations; Managed Care Programs; Models, Organizational; Public Health Administration; Tuberculosis; United States
PubMed: 9018283
DOI: No ID Found -
Bulletin of the World Health... 2000This article provides an overview of managed health care in the USA--what has been achieved and what has not--and some lessons for policy-makers in other parts of the... (Review)
Review
This article provides an overview of managed health care in the USA--what has been achieved and what has not--and some lessons for policy-makers in other parts of the world. Although the backlash by consumers and providers makes the future of managed care in the USA uncertain, the evidence shows that it has had a positive effect on stemming the rate of growth of health care spending, without a negative effect on quality. More importantly, it has spawned innovative technologies that are not dependent on the US market environment, but can be applied in public and private systems globally. Active purchasing tools that incorporate disease management programmes, performance measurement report cards, and alignment of incentives between purchasers and providers respond to key issues facing health care reform in many countries. Selective adoption of these tools may be even more relevant in single payer systems than in the fragmented, voluntary US insurance market where they can be applied more systematically with lower transaction costs and where their effects can be measured more precisely.
Topics: Humans; Managed Care Programs; Outcome Assessment, Health Care; Program Development; Program Evaluation; Quality Assurance, Health Care; Sensitivity and Specificity; United States
PubMed: 10916920
DOI: No ID Found -
The American Journal of Managed Care May 2009Attention-deficit/hyperactivity disorder (ADHD) often results in persistent problems with attention and impulsivity; these problems, in turn, contribute to impairments... (Review)
Review
Attention-deficit/hyperactivity disorder (ADHD) often results in persistent problems with attention and impulsivity; these problems, in turn, contribute to impairments in a wide range of functions that affect academic, social, and workplace performance. The chronic and cumulative effects of these difficulties can be overwhelming and outline the significant burden of illness associated with ADHD, which is realized in diminished quality of life for patients and their families and increasing costs or loss of revenue for payers and employers. This burden warrants significant consideration and action from managed care stakeholders to foster sound clinical practice and optimal care. For example, educational interventions and evidence-based tools can be implemented to assist providers with accurate diagnosis and more effective treatment. Furthermore, extensive data documenting the benefits of pharmacotherapy and provider follow-up have demonstrated that initiatives designed to encourage treatment adherence may be the best investment for managed care plans seeking to improve outcomes in patients with ADHD.
Topics: Attention Deficit Disorder with Hyperactivity; Cost of Illness; Efficiency; Efficiency, Organizational; Humans; Managed Care Programs; Outcome Assessment, Health Care; Patient Education as Topic; Practice Guidelines as Topic; Psychometrics; Quality of Life; United States
PubMed: 19601690
DOI: No ID Found -
The American Journal of Managed Care Aug 1997Each strategy for managing healthcare risk has important and unique implications for the patient-provider relationship and for quality of care. Not only are different... (Review)
Review
Each strategy for managing healthcare risk has important and unique implications for the patient-provider relationship and for quality of care. Not only are different incentive structures created by different risk-sharing arrangements, but these incentives differ from those in a fee-for-service environment. With fee-for-service and traditional indemnity insurance, physicians have incentives to provide healthcare services of marginal value to the patient; under managed care, physicians have fewer incentives to provide marginally beneficial services. However, the impact of financial arrangements on quality of care remains ambiguous, because it depends on the strategic behavior of physicians with regard to their informational advantage over their patients. Using the framework of an agency theory model, we surveyed the current scientific literature to assess the impact of managed care on quality of care. We considered three different dimensions of quality of care: patient satisfaction, clinical process and outcomes of care measures, and resource utilization. Although we found no systematic differences in patient satisfaction and clinical process and outcomes between managed care and fee-for-service plans, resource utilization appears to be decreased under managed care arrangements. Given the strengths and weaknesses of fee-for-service and managed care, it is unlikely that either will displace the other as the exclusive mechanism for arranging health insurance contracts. Policy makers may be able to take advantage of the strengths of both fee-for-service and managed care financial arrangements.
Topics: Delivery of Health Care, Integrated; Health Policy; Humans; Managed Care Programs; Outcome and Process Assessment, Health Care; Patient Satisfaction; Physician Incentive Plans; Quality of Health Care; Risk Management; United States; Utilization Review
PubMed: 10170299
DOI: No ID Found