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PloS One 2017Studies have shown large variation of referral probabilities in different countries, and many influencing factors have been described. This variation is most likely...
Studies have shown large variation of referral probabilities in different countries, and many influencing factors have been described. This variation is most likely explained by different healthcare systems, particularly to which extent primary care physicians (PCPs) act as gatekeepers. In Switzerland no mandatory gatekeeping system exists, however insurance companies offer voluntary managed care plans with reduced insurance premiums. We aimed at investigating the role of managed care plans as a potential referral determinant in a non-gatekeeping healthcare system. We conducted a cross-sectional study with 90 PCPs collecting data on consultations and referrals in 2012/2013. During each consultation up to six reasons for encounters (RFE) were documented. For each RFE PCPs indicated whether a referral was initiated. Determinants for referrals were analyzed by hierarchical logistic regression, taking the potential cluster effect of the PCP into account. To further investigate the independent association of the managed care plan with the referral probability, a hierarchical multivariate logistic regression model was applied, taking into account all available data potentially affecting the referring decision. PCPs collected data on 24'774 patients with 42'890 RFE, of which 2427 led to a referral. 37.5% of patients were insured in managed health care plans. Univariate analysis showed significant higher referral rates of patients with managed care plans (10.7% vs. 8.5%). The difference in referral probability remained significant after controlling for other confounders in the hierarchical multivariate regression model (OR 1.355). Patients in managed care plans were more likely to be referred than patients without such a model. These data contradict the argument that patients in managed care plans have limited healthcare access, but underline the central role of PCPs as coordinator of care.
Topics: Adult; Cross-Sectional Studies; Female; Humans; Male; Managed Care Programs; Middle Aged; Primary Health Care; Referral and Consultation; Switzerland
PubMed: 29112975
DOI: 10.1371/journal.pone.0186307 -
Cleveland Clinic Journal of Medicine Feb 1997
Topics: Chronic Disease; Cost-Benefit Analysis; Disease Management; Humans; Managed Care Programs; Medicine; Physician's Role; Specialization
PubMed: 9046681
DOI: 10.3949/ccjm.64.2.67 -
Journal of Managed Care Pharmacy : JMCP Apr 2005To review the role of the National Committee for Quality Assurance (NCQA) in ensuring the quality of care in the managed care setting and identify novel strategies to... (Review)
Review
OBJECTIVE
To review the role of the National Committee for Quality Assurance (NCQA) in ensuring the quality of care in the managed care setting and identify novel strategies to improve performance rates for Health Plan Employer Data and Information Set (HEDIS) measures, particularly in the area of depression.
SUMMARY
NCQA, by regulating HEDIS measures, sets the standards by which managed care organizations evaluate their performance in providing care for their enrollees. The medication management measure for depression evaluates practitioner contacts and acute and continuation phase treatments for persons treated with an antidepressant. Despite increased detection and management of patients with depression, there is still room for improvement in HEDIS performance rates for this chronic disease.
CONCLUSION
NCQA hopes to improve collaboration among managed care organizations and managed behavioral health organizations In addition, NCQA regularly reevaluates the HEDIS measures using input from panels of experts. Incentive p r o grams for providers who deliver quality care may also help to improve HEDIS performance rates for depression. Research is under way to evaluate the feasibility and re t u rn on investment for pay-for-performance programs in depression.
Topics: Antidepressive Agents; Depressive Disorder; Humans; Managed Care Programs; Quality Assurance, Health Care; United States
PubMed: 15804202
DOI: 10.18553/jmcp.2005.11.3.s9 -
Psychiatric Services (Washington, D.C.) Apr 2018The 2008 Mental Health Parity and Addiction Equity Act (MHPAEA) sought to improve access to behavioral health care by regulating health plans' coverage and management of...
OBJECTIVE
The 2008 Mental Health Parity and Addiction Equity Act (MHPAEA) sought to improve access to behavioral health care by regulating health plans' coverage and management of services. Health plans have some discretion in how to achieve compliance with MHPAEA, leaving questions about its likely effects on health plan policies. In this study, the authors' objective was to determine how private health plans' coverage and management of behavioral health treatment changed after the federal parity law's full implementation.
METHODS
A nationally representative survey of commercial health plans was conducted in 60 market areas across the continental United States, achieving response rates of 89% in 2010 (weighted N=8,431) and 80% in 2014 (weighted N=6,974). Senior executives at responding plans were interviewed regarding behavioral health services in each year and (in 2014) regarding changes. Student's t tests were used to examine changes in services covered, cost-sharing, and prior authorization requirements for both behavioral health and general medical care.
RESULTS
In 2014, 68% of insurance products reported having expanded behavioral health coverage since 2010. Exclusion of eating disorder coverage was eliminated between 2010 (23%) and 2014 (0%). However, more products reported excluding autism treatment in 2014 (24%) than 2010 (8%). Most plans reported no change to prior-authorization requirements between 2010 and 2014.
CONCLUSIONS
Implementation of federal parity legislation appears to have been accompanied by continuing improvement in behavioral health coverage. The authors did not find evidence of widespread noncompliance or of unintended effects, such as dropping coverage of behavioral health care altogether.
Topics: Health Services Accessibility; Humans; Insurance, Health; Managed Care Programs; Mental Health Services; Substance-Related Disorders; United States
PubMed: 29334882
DOI: 10.1176/appi.ps.201700203 -
The American Journal of Managed Care Aug 2012To examine the association between preventable hospitalization rates and proportions of managed care enrollment at the primary care service area level.
OBJECTIVE
To examine the association between preventable hospitalization rates and proportions of managed care enrollment at the primary care service area level.
STUDY DESIGN
Multivariate design.
METHODS
The study used the Healthcare Cost and Utilization Project State Inpatient Data from the Agency for Healthcare Research and Quality for Arizona, Massachusetts, and New York for the years 1995 and 2005 to examine the association between preventable hospitalization rates and proportions of managed care enrollment in 1995 and 2005. The period 1995-2005 was marked by the beginning and end of several legislative and policy initiatives causing changes in elderly hospitalization patterns as well as Medicare managed care enrollment patterns. The study used ordinary least squares regressions, adjusting for heteroscedasticity. A cross-sectional analysis was used to examine the association each year. A pooled sample analysis over years tested the changes in relative contributions of managed care over time.
RESULTS
Preventable hospitalization rates were inversely associated with Medicare managed enrollment in both years. This association was, however, found to be weaker in 2005 than in 1995. The decline in contributions of managed care was also statistically significant.
CONCLUSIONS
Despite increased managed care enrollment, the role of Medicare managed care in explaining declines in preventable hospitalization rates diminished over time. The results could be explained by the growth of private fee-for-service types of managed care plans and the resultant decline in emphasis on care coordination relative to health maintenance organization plans.
Topics: Aged; Aged, 80 and over; Arizona; Health Services Research; Hospitalization; Humans; Managed Care Programs; Massachusetts; Medicare; Multivariate Analysis; New York; Small-Area Analysis; United States
PubMed: 22928797
DOI: No ID Found -
Health Care Financing Review 1995The massive shift to managed care in many State Medicaid programs heightens the importance of identifying effective approaches to promote and oversee quality in plans... (Review)
Review
The massive shift to managed care in many State Medicaid programs heightens the importance of identifying effective approaches to promote and oversee quality in plans serving Medicaid enrollees. This article reviews operational issues and lessons from the ongoing evaluation of a three-State demonstration of the Health Care Financing Administration's (HCFA) Quality Assurance Reform Initiative (QARI) for Medicaid managed care. The QARI experience to date shows the potential utility of the system while drawing attention to the challenges involved in translating theory to practice. These challenges include data limitations and staffing constraints, diverse levels of sophistication among States and health plans, and the practical limitations of using quality indicators for a population that is often enrolled only on a discontinuous basis. To overcome these challenges, we suggest using realistically long timeframes for system implementation, with intermediate short-term strategies that could treat States and managed-care plans differently depending on their stage of development.
Topics: Centers for Medicare and Medicaid Services, U.S.; Guidelines as Topic; Health Services Research; Managed Care Programs; Medicaid; Pilot Projects; Program Evaluation; Quality Assurance, Health Care; State Health Plans; United States
PubMed: 10151896
DOI: No ID Found -
The American Journal of Managed Care Sep 1997This study was designed to identify the key components of physicians' attitudes toward managed care and develop a tool to assess these components. We developed a...
This study was designed to identify the key components of physicians' attitudes toward managed care and develop a tool to assess these components. We developed a questionnaire based on physicians' reactions to managed care, as reflected in the published literature. We mailed this questionnaire to a sample of 753 community physicians in the greater Sacramento area. A factor analysis of these data (n = 315) identified five unifactorial scales, which we labeled managed care quality, need to adapt to managed care, cost-containment effectiveness of managed care, personal knowledge of managed care, and inevitability of managed care. Physicians were most negative about the quality of managed care and most in agreement about the need to adapt to it. Correlations among these five scales, while statistically significant, were modest in size, suggesting that these physicians were quite discriminating in their evaluations. In comparison with medical/surgical specialists, primary care physicians rated the quality of managed care, their knowledge of it, and the inevitability of a national transition to managed care more positively. These measures predicted the physicians' intentions to alter their medical behaviors to comply with managed care practices.
Topics: Attitude of Health Personnel; California; Data Collection; Family Practice; Health Knowledge, Attitudes, Practice; Health Services Research; Health Workforce; Humans; Managed Care Programs; Physicians; Practice Patterns, Physicians'; Referral and Consultation; Specialization; Surveys and Questionnaires
PubMed: 10178478
DOI: No ID Found -
The American Journal of Managed Care Jan 2001In part 1 of "Drugs and the Elderly" (December 2000 issue), we reviewed and summarized the vast amount of clinical information on medication use in the elderly for... (Review)
Review
OBJECTIVE
In part 1 of "Drugs and the Elderly" (December 2000 issue), we reviewed and summarized the vast amount of clinical information on medication use in the elderly for healthcare providers and administrators within managed care. In part 2, we explore the literature on improving prescribing, focusing on those approaches most likely to be useful within a managed care environment.
STUDY DESIGN
We reviewed the general literature on medication use in the elderly, focusing on problems and systems approaches to the improvement of medication use in managed care. We created a topic list of general interest to health professionals within managed care and fit the available information into those topics. Thus, the result is an authoritative review rather than a systematic literature review.
PATIENTS AND METHODS
Nonquantitative evaluation of the medical literature.
RESULTS
We identified several hundred articles describing issues related to medication use in the elderly but only a trivial number that in any way addressed the managed care community directly. There is very little literature on how managed care can best incorporate the lessons of geriatric pharmacology and pharmacy.
CONCLUSIONS
There is a paucity of literature for the managed care community of health professionals regarding pharmacology, pharmacoepidemiology, drug utilization review, and other issues related to the use of medication in the elderly population.
Topics: Aged; Drug Prescriptions; Drug Utilization Review; Humans; Managed Care Programs; Patient Compliance; Practice Patterns, Physicians'; United States
PubMed: 11209451
DOI: No ID Found -
Health Services Research Dec 2003To examine the relationship between features of managed care organizations (MCOs) and health care use patterns by children.
OBJECTIVE
To examine the relationship between features of managed care organizations (MCOs) and health care use patterns by children.
DATA SOURCES
Telephone survey data from 2,223 parents of children with special health care needs, MCO-administrator interview data, and health care claims data.
STUDY DESIGN
Cross-sectional survey data from families about the number of consequences of their children's conditions and from MCO administrators about their plans' organizational features were used. Indices reflecting the MCO characteristics were developed using data reduction techniques. Hierarchical models were developed to examine the relationship between child sociodemographic and health characteristics and the MCO indices labeled: Pediatrician Focused (PF) Index, Specialist Focused (SF) Index, and Fee for Service (FFS) Index, and outpatient use rates and charges, inpatient admissions, emergency room (ER) visits, and specialty consultations.
DATA COLLECTION/EXTRACTION METHODS
The telephone and MCO-administrator survey data were linked to the enrollment and claims files.
PRINCIPAL FINDINGS
The child's age, gender, and condition consequences were consistent predictor variables related to health care use and charges. The PF Index was associated with decreased outpatient use rates and charges and decreased inpatient admissions. The SF Index was associated with increased ER visits and decreased specialty consultations, while the FFS Index was associated with increased outpatient use rates and charges.
CONCLUSION
After controlling for sociodemographic and health characteristics, the PF, SF, and FFS indices were significantly associated with children's health care use patterns.
Topics: Adolescent; Adult; Child; Child Health Services; Child, Preschool; Cross-Sectional Studies; Disabled Children; Emergency Service, Hospital; Female; Health Care Surveys; Humans; Male; Managed Care Programs; Regression Analysis; United States
PubMed: 14727790
DOI: 10.1111/j.1475-6773.2003.00195.x -
American Journal of Public Health Dec 2000
Topics: Community Health Planning; Delivery of Health Care, Integrated; Forecasting; Humans; Managed Care Programs; Organizational Objectives; Public Health Practice; Reimbursement Mechanisms; United States
PubMed: 11111248
DOI: 10.2105/ajph.90.12.1823