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Medicine Jun 2020To examine the impact of increased managed care activity on 30-day readmission and mortality for acute myocardial infarctions and congestive heart failure in U.S.... (Observational Study)
Observational Study
To examine the impact of increased managed care activity on 30-day readmission and mortality for acute myocardial infarctions and congestive heart failure in U.S. hospitals following the managed care backlash against managed care cost containment practices.The Centers for Medicare and Medicaid Services (CMS) Hospital Compare files, CMS Hospital Cost Report, CMS Medicare Advantage Enrollment files, and Health Resources and Services Administration Area Resource File data for the period 2008 to 2011 were used to construct the study sample. Multivariate fixed effects regression with robust standard errors, hospital fixed effects, and year fixed effects were used to estimate the impact of managed care penetration on adverse cardiovascular outcomes. Our primary outcome measures were readmission and mortality for patients discharged with acute myocardial infarction and congestive heart failure for acute, non-federal hospitals with emergency rooms. To examine effects of hospital ownership status, not-for-profit hospitals were compared to proprietary hospitals.The main analysis revealed that an increase in managed care penetration was associated with a decline in both 30-day readmission and mortality for acute myocardial infarction and congestive heart failure. In the hospital ownership analysis, only the acute myocardial infarction results for proprietary hospitals was statistically significant. All hospital types reported similar congestive heart failure trends as the full sample; however, proprietary hospitals reported greater declines in readmission and mortality.Increased managed care activity is associated with reductions in hospital readmission and mortality following the legislative and consumer backlash against managed care, with differential impacts across hospital ownership type. These finding highlights the important role of managed care in creating quality improvements in the delivery of care in the hospital setting.
Topics: Centers for Medicare and Medicaid Services, U.S.; Female; Heart Failure; Hospitals; Humans; Incidence; Male; Managed Care Programs; Medicare Part C; Myocardial Infarction; Patient Readmission; Quality Indicators, Health Care; United States
PubMed: 32502045
DOI: 10.1097/MD.0000000000020636 -
Missouri Medicine 2018
Topics: Humans; Managed Care Programs; United States
PubMed: 30228762
DOI: No ID Found -
Journal of Managed Care & Specialty... Mar 2021Despite the opportunity for large health gains, there are many challenges associated with rare disease therapies. Among these are striking the appropriate balance...
Despite the opportunity for large health gains, there are many challenges associated with rare disease therapies. Among these are striking the appropriate balance between the urgency to respond to patient needs with the uncertainty that is often inherent in rare disease therapy datasets leading to concerns with developing and interpreting clinical data; uncertainty around financial impact, value determination, and affordability; and variation in approach to coverage and potential effects on access. To discuss these challenges and opportunities to address them, AMCP held a virtual multidisciplinary stakeholder forum on September 8-10, 2020. Forum participants represented diverse sectors of the health care industry, including integrated delivery systems, health plans, pharmacy benefit managers, employer groups, biopharmaceutical companies, patient advocacy organizations, health policy researchers, and consulting firms; they evaluated strategies to plan for and manage rare disease therapies and recommended best practices and next steps. This forum was sponsored by the following: AstraZeneca, Dicerna, Genentech, National Pharmaceutical Council, Novo Nordisk, Pfizer, Precision Value, Sanofi, Sarepta Therapeutics, Seattle Genetics, Spark Therapeutics, and Takeda. These proceedings were prepared as a summary of the forum to represent common themes; they are not necessarily endorsed by all attendees nor should they be construed as reflecting group consensus.
Topics: Humans; Managed Care Programs; Pharmaceutical Services; Public-Private Sector Partnerships; Rare Diseases; Stakeholder Participation; United States
PubMed: 33538235
DOI: 10.18553/jmcp.2021.20546 -
Inquiry : a Journal of Medical Care... 2008This study assesses the ability of managed care to contain hospital costs since the managed care backlash, using data from California's Office of Statewide Health...
This study assesses the ability of managed care to contain hospital costs since the managed care backlash, using data from California's Office of Statewide Health Planning and Development for all acute-care hospitals in the state for the period 1991-2001. The analysis employs a long-differences design to examine cost growth before and after the managed care backlash. Results from the early 1990s are consistent with prior evidence that the combination of more competitive markets and high managed care penetration held down costs. Post-backlash, high managed care penetration no longer was associated with lower cost growth in the most competitive markets, indicating that the synergistic effects between managed care and hospital competition no longer may exist.
Topics: California; Economic Competition; Hospital Costs; Humans; Managed Care Programs; Quality of Health Care
PubMed: 18524295
DOI: 10.5034/inquiryjrnl_45.01.98 -
The American Journal of Managed Care Jun 2020Scholars have highlighted the importance of preventing hospital admissions and readmissions for individuals with costly chronic conditions. Providing effective care...
OBJECTIVES
Scholars have highlighted the importance of preventing hospital admissions and readmissions for individuals with costly chronic conditions. Providing effective care management strategies can help reduce inpatient admissions, thereby reducing rising health care costs. However, implementing effective care management strategies may be more difficult for independent physician associations (IPAs) that contract with multiple organizations that have competing interests and agendas. This study aims to identify and investigate strategies that facilitate the implementation of evidence-based best practices among IPAs.
STUDY DESIGN
The research synthesized peer-reviewed literature to identify best practices in chronic disease management for Medicare beneficiaries. Subsequently, 20 key informant interviews were conducted to explore barriers and facilitators in adapting these best practices in IPA settings. Informant interviews were conducted with 3 key groups: executives, medical directors, and care managers.
METHODS
Key informant interviews were conducted to explore barriers and facilitators in implementing best care management practices.
RESULTS
Key informants provided unique insights regarding the challenges of implementing best care management practices among IPAs. These challenges included implementing and sustaining the operations of evidence-based care management programs while maintaining contractual obligations to health plans, engaging physicians in large and diverse networks, and building high-touch programs in large geographic areas using risk-stratifying algorithms.
CONCLUSIONS
IPA managed care organizations require unique considerations in regard to selected strategies used to manage chronic disease in Medicare populations. These considerations are critical for optimal management of the population, particularly in a risk-based or pay-for-performance environment.
Topics: Adult; Clinical Protocols; Evidence-Based Practice; Female; Health Personnel; Humans; Male; Managed Care Programs; Middle Aged; Physicians; Practice Guidelines as Topic; Practice Patterns, Physicians'; Qualitative Research; United States
PubMed: 32549063
DOI: 10.37765/ajmc.2020.43489 -
Health Services Research Oct 2005To determine whether gender differences in reports of problematic health care experiences are associated with characteristics of managed care. (Comparative Study)
Comparative Study
OBJECTIVE
To determine whether gender differences in reports of problematic health care experiences are associated with characteristics of managed care.
DATA SOURCES
The 2002 Yale Consumer Experiences Survey (N=5,000), a nationally representative sample of persons over 18 years of age with private health insurance, Interstudy Competitive Edge HMO Industry Report 2001, Area Resource File 2002, and the American Hospital Association Annual Survey of Hospitals 2002.
STUDY DESIGN
Independent and interactive effects of gender and managed care on reports of problematic health care experiences were modeled using weighted multivariate logistic regression.
PRINCIPAL FINDINGS
Women were significantly more likely to report problems with their health care compared with men, even after controlling for gendered differences in expectations about medical care. Gender disparities in problem reporting were larger in plans that used certain managed care techniques, but smaller in plans using other methods. Some health plan managed care practices, including closed networks of providers and gatekeepers to specialty care, were associated with greater problem reporting among women, while others, such as requirements for primary care providers, were associated with greater problem reporting among men. Markets with higher HMO competition and penetration were associated with greater problem reporting among women, but reduced problem reporting among men. Women reported more problems in states that had enacted regulations governing access to OB/GYNs, while men reported more problems in states with regulations allowing specialists to act as primary care providers in health plans.
CONCLUSIONS
There are nontrivial gender disparities in reports of problematic health care experiences. The differential consequences of managed care at both the plan and market levels explain a portion of these gender disparities in problem reporting.
Topics: Female; Government Regulation; Health Care Sector; Health Care Surveys; Health Services Accessibility; Health Services Needs and Demand; Health Status Indicators; Humans; Logistic Models; Male; Managed Care Programs; Patient Satisfaction; Quality of Health Care; Sex Factors; Socioeconomic Factors; United States
PubMed: 16174144
DOI: 10.1111/j.1475-6773.2005.00422.x -
Journal of Managed Care Pharmacy : JMCP Jan 2006To review managed care's current cost management trends and the consumerism movement; to elucidate the pros and cons of key issues; and to describe the philosophy of...
OBJECTIVE
To review managed care's current cost management trends and the consumerism movement; to elucidate the pros and cons of key issues; and to describe the philosophy of focusing on the patient, also called patient-centric care, while improving the patient's care through value-based purchasing and plan design.
SUMMARY
Managed care is sometimes practiced using a silo approach with little concern for the consumer. In this model, medical and pharmaceutical issues are addressed in silos, and value is narrowly defined. Increasingly, cost and responsibility is shared with or shifted to the patients. Patients may be unable or unwilling to assume these costs or responsibilities. Several studies have demonstrated that they may react with noncompliance. Managed care's definition of value must expand and integrate across silos to consider the needs and interests of the patient's overall care, in particular, addressing key cost drivers in terms of diseases that cause recurring costs. Using predictive modeling can result in cost savings. A case study (Pitney Bowes) is included in this article.
Topics: Cost Control; Humans; Managed Care Programs; Models, Organizational; Organizational Case Studies; Patient Care Management; Patient-Centered Care; Pharmaceutical Services; United States
PubMed: 16674274
DOI: 10.18553/jmcp.2006.12.s1-A.S10 -
The Western Journal of Medicine May 1998Medical schools, teaching hospitals, and managed care organizations have a vested interest in shaping the knowledge, skills, and attitudes of the next generation of... (Review)
Review
Medical schools, teaching hospitals, and managed care organizations have a vested interest in shaping the knowledge, skills, and attitudes of the next generation of physicians who must adapt to significant changes in the financing and delivery of health care. This article summarizes the rationale for educational partnerships between managed care and academic medicine based on a review of three decades of well-documented experimentation in the literature. Discussed are some of the most important characteristics of the successful partnerships being forged in the current healthcare environment based on new kinds of relationships between faculty and non-university clinician educators. What had been referred to in previous decades as the "teaching-HMO" is now being complemented by community-based links between academic health centers and managed care plans. Several public and private sources have been generous in providing venture capital to support many of these innovations. However, their continued operation will depend on models for health care networks that can identify and manage the revenue and costs associated with the missions of education, clinical services, and research.
Topics: Academic Medical Centers; Delivery of Health Care, Integrated; Education, Medical, Graduate; Humans; Managed Care Programs; Quality Control; Regional Medical Programs; United States
PubMed: 9614788
DOI: No ID Found -
The American Journal of Managed Care Dec 2000Alzheimer's disease (AD) and dementia are responsible for high levels of excess per-member costs within managed care organizations (MCOs). To deal with anticipated... (Review)
Review
Alzheimer's disease (AD) and dementia are responsible for high levels of excess per-member costs within managed care organizations (MCOs). To deal with anticipated increases in the prevalence of this disease within their populations, MCOs should take steps to integrate and target proven pharmacologic and non-pharmacologic AD treatments. Key areas of AD care improvement include protocol-driven diagnosis, referral, and treatment; education of primary care physicians and caregivers; development of an integrated case management approach; and use of validated measures to assess outcomes. Published evidence-based guidelines are available to assist MCOs in developing clinical protocols for diagnosis and treatment with effective agents such as cholinesterase inhibitors. Because of the opportunity to prevent costly hospitalizations and other complications as a result of medical and behavioral comorbidities, and because of the need for tightly integrated care, a disease management approach for AD may be justified.
Topics: Aged; Aged, 80 and over; Alzheimer Disease; Cost Control; Decision Making, Organizational; Disease Management; Humans; Managed Care Programs; Practice Guidelines as Topic; Prevalence; United States
PubMed: 11142179
DOI: No ID Found -
Journal of the National Medical... May 2001The medical profession will face many challenges in the new millennium. As medicine looks forward to advances in molecular genetics and the prospect of unprecedented... (Review)
Review
The medical profession will face many challenges in the new millennium. As medicine looks forward to advances in molecular genetics and the prospect of unprecedented understanding of the causes and cures of human disease, clinicians, scientists and bioethicists may benefit from reflection upon the origins of the medical ethos and its relevance to postmodern medicine. Past distortions of the medical ethos, such as Nazism and the Tuskegee Syphilis Study, as well as more recent experience with the ethical challenges of employer-based market driven managed care, provide important lessons as medicine contemplates the future. Racial and ethnic disparities in health status and access to care serve as a reminders that the racial doctrines that fostered the horrors of the Holocaust and the Tuskegee Syphilis Study have not been completely removed from contemporary thinking. Inequalities in health status based on race and ethnicity, as well as socioeconomic status, attest to the inescapable reality of racism in America. When viewed against a background of historical distortions and disregard for the traditional tenets of the medical ethos, persistent racial and ethnic disparities and health and the prospect of genetic engineering raise the specter of discrimination because of genotype, a postmodern version of "racist medicine" or of a "new eugenics." There is a need to balance medicine's devotion to the wellbeing of the patient and the primacy of the patient-physician relationship against with the need to meet the health care needs of society. The challenge facing the medical profession in the new millennium is to establish an equilibrium between the responsibility to assure quality health care for the individual patient while affecting societal changes to achieve "health for all."
Topics: Black People; Clinical Medicine; Ethics, Medical; Female; Forecasting; Humans; Male; Managed Care Programs; Political Systems; Refusal to Treat; Research; Social Responsibility; Syphilis; United States
PubMed: 11405593
DOI: No ID Found