-
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 -
The American Journal of Managed Care Jan 2002TennCare, the statewide Medicaid managed care system implemented in Tennessee on January 1, 1994, sought to reduce state and federal healthcare expenditures while... (Review)
Review
TennCare, the statewide Medicaid managed care system implemented in Tennessee on January 1, 1994, sought to reduce state and federal healthcare expenditures while enhancing access to and quality of care. TennCare currently covers 1.32 million enrollees (25% of the citizens of Tennessee), including more than 520,248 citizens previously not covered by health insurance. It is one of the largest Medicaid managed care enterprises in the nation and the only program to cover uninsurables regardless of income. Utilization of preventive and primary care services has increased, and selected measures of quality of care have improved. Program costs from 1994 through 1998 rose at a rate below that of overall US Medicaid costs during the same period, resulting in modest savings. However, managed care plans, hospitals, and individual providers continue to report substantial fiscal losses, and managed care organizations--including the 3 largest plans in the program--have closed, been placed under receivership, or threatened to withdraw from the market. Furthermore, safety net hospitals, academic medical centers, and community mental health programs have fared financial cutbacks that have limited their ability to serve the remaining uninsured as well as the insured. Because of these fiscal difficulties, the TennCare program is now in significant jeopardy despite its important clinical successes. Major structural and fiscal changes will be required if the program is to continue to enhance services and remain financially viable. This report focuses on TennCare's successes and failures to offer lessons for Medicaid managed care programs nationwide.
Topics: Academic Medical Centers; Bankruptcy; Economics, Hospital; Health Expenditures; Health Services Accessibility; Humans; Managed Care Programs; Medicaid; Program Development; Program Evaluation; Quality of Health Care; State Health Plans; Tennessee; United States
PubMed: 11814173
DOI: No ID Found -
Journal of Managed Care & Specialty... Apr 2020Research agendas play valuable roles in clearly identifying high-priority topics that reflect potential to improve health care quality. The purpose of this report is to...
Research agendas play valuable roles in clearly identifying high-priority topics that reflect potential to improve health care quality. The purpose of this report is to present work completed by the Academy of Managed Care Pharmacy (AMCP) and AMCP Foundation Joint Research Committee. This committee set forth to develop a research agenda for our 2 organizations that focuses on critical evidence needs in managed care pharmacy. This document reviews results from 2 surveys that were conducted to better understand unmet research needs within managed care pharmacy and to inform professional efforts of managed care pharmacists. The first survey collected qualitative data from key opinion leaders (KOLs) regarding the top evidentiary gaps in managed care pharmacy and barriers to closing those gaps. The second survey was sent to AMCP members and AMCP Foundation stakeholders, used a mixed methods quantitative-qualitative design, and incorporated concepts from initial KOL responses. The key outcome from these proceedings is the research agenda, which identifies and prioritizes 4 evidentiary gaps in managed care pharmacy: (1) real-world evidence to inform managed care pharmacy decision making, (2) value-based models in managed care pharmacy to address total cost of care, (3) impact of benefit design or utilization management strategies on patient outcomes, and (4) impact of direct patient care services provided by managed care pharmacy on patient outcomes. The agenda was intended to be broad and will evolve over time. AMCP and the AMCP Foundation hope that this research agenda inspires the AMCP membership, researchers, and funding agencies to close these gaps in knowledge and understanding. DISCLOSURES: Chairs and members of the Joint Research Committee oversaw and conducted the work outlined in this report with the support of AMCP and the AMCP Foundation. No outside funding was received. Gembarski, Couto, Wilson, and Eichenbrenner declare no conflicts of interest, real or apparent, with any product or service mentioned in this report. Gembarski is employed by BCBS Michigan; Couto is employed by Cigna; Wilson is employed by HealthCore, a wholly owned subsidiary of Anthem; and Eichenbrenner is employed by the AMCP Foundation.
Topics: Managed Care Programs; Pharmaceutical Services; Pharmacy Research; Pharmacy and Therapeutics Committee; Professional Practice Gaps
PubMed: 32130069
DOI: 10.18553/jmcp.2020.19372 -
Journal of Managed Care & Specialty... May 2019Managed care organizations are growing more sophisticated in their ability to analyze data. There are increasing numbers of data analysts at managed care organizations,...
Managed care organizations are growing more sophisticated in their ability to analyze data. There are increasing numbers of data analysts at managed care organizations, as well as more types of real-time, or "live," data available. These data range from pharmacy claims and enrollment files to medical claims, medical records, and linkages to external data. Moreover, the data are often curated in a way that allows for easier data analysis. Using these data, managed care residents are often required to perform a project to evaluate a utilization management policy or clinical program. Yet, there is a lack of guidance specific to managed care organizations on how to conduct such a research study using "live" claims data. This Viewpoint article provides a primer for managed care residents and other managed care professionals who are seeking to use data to help inform decisions on how to manage their beneficiaries' health and costs. DISCLOSURES: There was no funding source for this manuscript. Hung reports a grant from the Agency for Healthcare Research and Quality and personal fees from Blue Cross Blue Shield Association, outside the submitted work. Gedey, Groeneweg, and Jay have nothing to disclose.
Topics: Data Interpretation, Statistical; Humans; Insurance Claim Review; Internship and Residency; Managed Care Programs; Pharmaceutical Services; Pharmacy Research; Research Design; United States
PubMed: 31039066
DOI: 10.18553/jmcp.2019.25.5.538 -
Journal of Community Health Jun 2012We describe the impact of community health workers (CHWs) providing community-based support services to enrollees who are high consumers of health resources in a...
We describe the impact of community health workers (CHWs) providing community-based support services to enrollees who are high consumers of health resources in a Medicaid managed care system. We conducted a retrospective study on a sample of 448 enrollees who were assigned to field-based CHWs in 11 of New Mexico's 33 counties. The CHWs provided patients education, advocacy and social support for a period up to 6 months. Data was collected on services provided, and community resources accessed. Utilization and payments in the emergency department, inpatient service, non-narcotic and narcotic prescriptions as well as outpatient primary care and specialty care were collected on each patient for a 6 month period before, for 6 months during and for 6 months after the intervention. For comparison, data was collected on another group of 448 enrollees who were also high consumers of health resources but who did not receive CHW intervention. For all measures, there was a significant reduction in both numbers of claims and payments after the community health worker intervention. Costs also declined in the non-CHW group on all measures, but to a more modest degree, with a greater reduction than in the CHW group in use of ambulatory services. The incorporation of field-based, community health workers as part of Medicaid managed care to provide supportive services to high resource-consuming enrollees can improve access to preventive and social services and may reduce resource utilization and cost.
Topics: Community Health Services; Community Health Workers; Cost Savings; Health Services Research; Humans; Managed Care Programs; Medicaid; New Mexico; Outcome Assessment, Health Care; Patient Advocacy; Patient Education as Topic; Retrospective Studies; Social Support; United States
PubMed: 21953498
DOI: 10.1007/s10900-011-9484-1 -
Journal of Managed Care & Specialty... Jul 2014There is extensive literature demonstrating that formulary restrictions reduce the pharmacy costs and utilization of restricted drugs. However, some research suggests... (Review)
Review
A systematic literature review assessing the directional impact of managed care formulary restrictions on medication adherence, clinical outcomes, economic outcomes, and health care resource utilization.
BACKGROUND
There is extensive literature demonstrating that formulary restrictions reduce the pharmacy costs and utilization of restricted drugs. However, some research suggests that there may be unintended consequences of formulary restrictions on other patient outcomes. While several literature reviews have assessed the relationship between formulary restrictions and medication adherence, clinical outcomes, economic outcomes, or health care resource utilization, these reviews were either not systematic, were conducted more than 5 years ago, or did not assess the aggregate directional impact of the relationships.
OBJECTIVE
To conduct a systematic literature review assessing the direction (positive, negative, or neutral) of the relationship between managed care formulary restrictions (including step therapy, cost sharing, prior authorization, preferred drug lists, and quantity limits) on medication adherence, clinical outcomes, economic outcomes, and health care resource utilization.
METHODS
Articles published in 1993 or later were identified from PubMed using 2 lists of search terms. List A included 12 formulary restriction terms and List B included 12 patient outcomes terms, resulting in 144 unique search term combinations. Each article was evaluated by 2 investigators against the following exclusion criteria using a stepwise approach: (a) the article was a commentary or review article; (b) the article did not assess the impact of managed care formulary restrictions on outcomes; and (c) the study was conducted outside the United States. The total number of studies was reported by formulary restriction type. Next, the total number of outcomes reported in each study was summed to conduct an outcomes-level analysis. The outcomes were categorized by type of outcome (medication adherence, clinical, economic, or health care resource utilization) and direction of association (positive, negative, or neutral/not significant) based on the relationship reported in each study. The frequencies of each type of outcome were stratified by direction of association.
RESULTS
A total of 93 studies were included from 811 reviewed articles. Cost sharing was the most commonly assessed type of formulary restriction (60.2% of included articles), followed by prior authorization (21.5%). Of the 262 patient outcomes assessed, medication adherence was the most common (120 outcomes, 45.8%). Overall, formulary restrictions were most frequently negatively correlated with outcomes (130 outcomes, 49.6%). When outcome type was stratified by direction of association, 68.3% (82/120) of medication adherence outcomes were negative. The direction of association of economic outcomes (n = 59) with formulary restrictions was split between neutral (37.3%), positive (33.9%), and negative (28.8%). Health care resource utilization outcomes (n = 72) had no association with formulary restrictions in 50.0% of the outcomes assessed. There were 11 clinical outcomes identified in the literature review.
CONCLUSIONS
There is a strong evidence base demonstrating a negative correlation between formulary restrictions on medication adherence outcomes. Additional research on commonly used formulary restrictions, specifically prior authorization and step therapy, as well as on the association between formulary restrictions and clinical outcomes, is warranted.
Topics: Formularies as Topic; Health Services; Humans; Managed Care Programs; Medication Adherence; Outcome Assessment, Health Care
PubMed: 24967521
DOI: 10.18553/jmcp.2014.20.7.677 -
The Western Journal of Medicine Nov 1991The nation's health maintenance organizations, preferred-provider organizations, independent practice associations, and similar managed-care efforts are not well... (Review)
Review
The nation's health maintenance organizations, preferred-provider organizations, independent practice associations, and similar managed-care efforts are not well positioned to take a leadership role in a nationwide universal access or national health insurance plan. They--with the possible exception of some large staff and group health maintenance organizations--have been unable to show uniformly that they can contain costs, provide better access or higher quality of care, and achieve greater patient satisfaction than fee-for-service endeavors. As the United States pursues universal access as a step toward national health insurance, the managed-care plans will continue to increase their numbers of subscribers. They will not, however, be able to enroll large numbers of the young, low-income employees and their dependents who account for most of the 63 million people uninsured sometime during each year. Under national health insurance, there might be an option for some health maintenance organizations to negotiate capitated payments. The vast majority of the nation's physicians, however, will reluctantly embrace a centrally managed fee-for-service approach rather than a salary or capitated reimbursement method, leaving only a trace of the competitive managed-care plan theme in a future, primarily monolithic, national health care system.
Topics: Health Maintenance Organizations; Humans; Managed Care Programs; National Health Insurance, United States; Patient Satisfaction; Quality of Health Care; United States
PubMed: 1815407
DOI: No ID Found -
Journal of Managed Care & Specialty... Sep 2020
Topics: Anniversaries and Special Events; Humans; Managed Care Programs; Periodicals as Topic
PubMed: 32857649
DOI: 10.18553/jmcp.2020.26.9.1067 -
Journal of Managed Care Pharmacy : JMCP Nov 2008Prevalence studies estimate that chronic constipation affects 12%-19% of Americans. This prevalence rate exceeds that of many highly publicized chronic conditions,... (Review)
Review
BACKGROUND
Prevalence studies estimate that chronic constipation affects 12%-19% of Americans. This prevalence rate exceeds that of many highly publicized chronic conditions, including diabetes and asthma. Identifying the etiology of each patient's constipation is essential for determining treatment and management plans. The etiology of chronic constipation falls into 2 broad categories: primary or idiopathic constipation caused by physical and functional problems, and secondary constipation resulting from a variety of organic conditions as well as the use of certain medications. Patients may have more than one cause of their constipation. Treatment options may be based not only on the cause but may be dictated by a patient's health care coverage and the inclusion criteria of different health care plans.
OBJECTIVES
To (a) present key information on the causes, diagnosis, and treatment recommendations for patients with chronic constipation; (b) describe how chronic constipation impacts quality of life; and (c) describe how all providers can work to improve the quality of care and health outcomes for patients with chronic constipation.
SUMMARY
Chronic constipation is a prevalent condition that disproportionately affects women and the elderly. Most agents are available over-the-counter, although their efficacy has not been extensively tested. Few prescription agents are currently available, and they are more costly; therefore, managed care plans may restrict these products for patients who fail traditional treatments. A lack of evidence-based algorithms leaves many providers to treat patients empirically. Practitioners can assist patients seeking recommendations and provide information on treatment options.
Topics: Age Factors; Aged; Chronic Disease; Constipation; Female; Humans; Male; Managed Care Programs; Quality Assurance, Health Care; Quality of Life; Sex Factors; Treatment Outcome; United States
PubMed: 18950252
DOI: 10.18553/jmcp.2008.14.S8-A.1 -
North Carolina Medical Journal 2019As North Carolina's Medicaid program transitions from fee-for-service to managed care, the Department of Health and Human Services is committed to building an...
As North Carolina's Medicaid program transitions from fee-for-service to managed care, the Department of Health and Human Services is committed to building an innovative, whole-person-centered and well-coordinated system of care that addresses both medical and non-medical drivers of health. Delivering on that vision, and improving the health and well-being of North Carolinians, means shifting from thinking of payers as exclusively buying medical services to thinking of them as buying health for their beneficiaries. Operationalizing this complex work will require strong partnership from stakeholders across the state and will also provide North Carolina an opportunity to help drive a national agenda centered around how to buy good health.
Topics: Humans; Managed Care Programs; Medicaid; North Carolina; United States
PubMed: 31471508
DOI: 10.18043/ncm.80.5.277