Large Managed Care Organization Research Articles

Managed care pharmacy, socioeconomic assessments and drug adoption decisions

A telephone survey of a representative national sample of 51 large managed care organizations in the U.S. (> 50,000 enrollees) was undertaken (1) to understand the role of socioeconomic assessments on drug adoption decisions; (2) to determine the sources of these assessments and the reliance of managed care pharmacy on each; and (3) to determine the resources for internally versus externally performed drug assessments. Socioeconomic assessments (clinical effectiveness, safety, cost of treatment, cost-effectiveness, and quality of life) are often tied to formulary decisions. Plans differ in their use of externally available socioeconomic assessments and in their ratings of the importance to decision making of drug assessments from the various sources. Those using a specific source of drug assessment information rated them in the following order of importance: PBM assessments, other HMOs, peer reviewed literature, evaluations performed by industry, articles in non-peer reviewed publications and, lastly, government reports. Timeliness and comprehensiveness are important components of the overall utility of information. A high percentage of plans reported using some of the various types of assessments, with clinical effectiveness most common, and cost-effectiveness second. The percentage of new drugs that undergo assessments in each of the plans covers a broad range, with 57% of the plans evaluating at least half of all new drugs. All but one surveyed managed care plan reported having either implemented or plans to implement a disease management program. Eighty percent of those surveyed are more concerned about drug assessments than in the past and 88% anticipate greater future use. Although 38 plans (75%) have a person in the organization responsible for drug assessments, this is the primary job in only 14 plans (37%). With greater reliance on drug assessments in the future, there are substantial opportunities for integrating drug assessments, formularies and disease management programs.

Approaches to prostate cancer by managed care organizations

Objectives Managed care organizations (MCOs) are developing population-based approaches to illnesses with large numbers of patients, wide variations in care and outcomes, and high costs. This is the first survey that evaluates current prostate cancer approaches by MCOs. Methods Case studies and a survey of corporate medical directors at large MCOs were conducted. Results Two approaches, broadly based on disease management strategies for men with prostate cancer, have been implemented in managed care settings on the West Coast. While both have provided comprehensive approaches to the disease, assessment of improvement in outcomes will require longer follow-up. A survey of corporate medical directors of MCOs indicates that population-based disease approaches nationwide for malignant prostate disease lag behind more well-developed efforts for nonmalignant illnesses such as diabetes and asthma. Conclusions Prostate cancer may be a feasible area for development and evaluation of population-based approaches. MCOs have the potential to improve clinical care and outcomes for large numbers of men with prostate cancer. While limitations exist related to specific managed care considerations of data needs and lack of medical and surgical consensus on disease management, programs based on shared decision making have the potential to improve patient care and outcomes.

A Comparison of Satisfaction with Mail versus Traditional Pharmacy Services

OBJECTIVE: To determine the level of satisfaction with pharmacy services among enrollees of a managed care organization and to compare the level of satisfaction between mail pharmacy and traditional pharmacy patrons. DESIGN: Data were collected via telephone interviews with 1,362 enrollees of a large managed care organization with recent prescription claims. Scores were calculated for various hypothesized multi-item dimensions of satisfaction of pharmacy services. With one exception, internal-consistency reliability coefficients for the scales exceeded 0.50. Health status was also measured, using the physical and mental health composite scores of the 12-ltem Short Form (SF-12) Health Survey. Satisfaction with pharmacy services was compared between patron groups using tests and analysis of covariance (AN COVA) models. RESULTS: Mail pharmacy patrons were more satisfied than traditional pharmacy patrons with their pharmacy services in general (77.6 vs. 72.8, P=0.002), and specifically with the financial aspects and technical quality of those services. After adjusting for general satisfaction with medical care, health status, and select demographic variables, mail pharmacy patrons still had greater levels of general satisfaction with pharmacy services (P=0.036). Respondents with depressive symptoms were less satisfied with aspects of traditional pharmacy services than with mail services, and subjects with airway disease were less satisfied with the turnaround time for mailed prescriptions than for traditional services. CONCLUSION: The difference in satisfaction between the patron groups was not large and may not be of practical significance. However, variations in observed satisfaction scores between respondents with and without specific comorbid conditions may be useful from a policy and planning perspective.

Ventilation tube placement in a managed care population.

To date, little information is available regarding the actual incidence of ventilation tube placement in a known population of pediatric patients. We evaluated the incidence of ventilation tube placement in a known population of pediatric patients whose health coverage is provided through a large managed care organization. Epidemiological data provided by a large managed care organization on a population of 67,995 children from July 1, 1993, through June 30, 1994, were evaluated. A primary care physician referral to an otolaryngologist was required for assessment, and precertification for ventilation tube placement was obtained using explicit criteria developed by a large national health services utilization review organization. In children younger than 24 months, 30.11% underwent ventilation tube placement compared with an overall incidence of 4.49% for all children younger than 18 years. The details of this study are presented to understand better the implications of the epidemiology of otitis media and how it relates to a physician's participation in a managed care organization.

Identification of neonatal deaths in a large managed care organisation.

The neonatal (< 28 days) mortality rate (NMR) is one of the most commonly employed maternal and child health epidemiological measures. It is also being employed in quality measures ("report cards') used to assess the performance of health care organisations. The objectives were to (1) develop methods for the rapid quantification of the neonatal mortality rate in a multi-hospital system, the Kaiser Permanente Medical Care Program's Northern California Region (KPMCP NCR), (2) develop methods for generating facility-specific rates and case lists, and (3) ascertain the capture rates of the information sources available to us. Potential neonatal deaths were identified in the KPMCP NCR for the 1990 and 1991 calendar years from 3 sources: (1) clerical searches of local facility records, (2) electronic searches of the KPMCP NCR hospitalisation database, and (3) linking KPMCP electronic birth records to death certificate tapes. The medical records of all infants identified through these methods were reviewed. The neonatal mortality rate was calculated in three ways: (1) including all livebirths, (2) excluding births weighing < 500 g, and (3) adjusting for prematurity by increasing the follow-up period in preterm babies (these babies were included as neonatal deaths if they died up to 40 weeks corrected age + 27.9 days). A total of 352 records out of 64 469 birth records in the KPMCP NCR were reviewed. If one includes babies < 500 g, the neonatal mortality rate was 3.72/1000 livebirths; if these babies are excluded, the rate was 3.05/1000. Adjusting for prematurity increased these rates to 3.91/1000 and 3.24/1000, respectively. Accurate quantification of the neonatal mortality rate in a multi-hospital system requires the use of multiple information sources. Use of a single source can lead to varying rates of over- or under-estimation. It is possible to employ our methodology for both research and operational purposes.

Reforming the Health Care System to Meet the Needs of Older People: A Call for Papers

Reforming the Health Care System to Meet the Needs of Older People: A Call for Papers

28th Annual Meeting of the Society for Obstetric Anesthesia and Perinatology

28th Annual Meeting of the Society for Obstetric Anesthesia and Perinatology

Infertility services in a managed care environment

Managed care schemes are replacing traditional fee-for-service reimbursement to physicians and hospitals in the United States. Managed care schemes take the form of discounted fee-for-service, utilization review, global fee reimbursement, and capitated reimbursement schemes with funds to be distributed among providers. Reimbursement for infertility services has been excluded from many managed care plans as infertility is viewed as a social condition, not a medical condition, and coverage for infertility diagnosis and treatment is viewed as unnecessary in the bundle of services offered by insurers and other managed care organizations. However, some states mandate infertility coverage and some managed care organizations realize that provision of care for infertile couples makes their product more attractive. Large managed care organizations such as Blue Cross/Blue Shield of illinois and some entrepreneurial organizations are developing managed care plans that incorporate infertility services. Comprehensive services--including in-vitro fertilization--can be offered at a lower cost than traditional fee-for-service care. Newer technologies such as in-vitro fertilization are replacing fallopian tube surgery and surgical treatment for male infertility. These can be implemented at a lower cost and with better outcome for infertile couples than traditional services.

Postdischarge Utilization of Medical Services by High-risk Infants: Experience in a Large Managed Care Organization

Infants discharged from intensive care nurseries are a high-risk infant (HRI) population known to have increased utilization of medical services. Most studies tracking HRIs have been based on data obtained from individual chart review or direct patient contact. Given the high cost of such studies, it is desirable to develop less costly methods to track such infants. Our goals were: (1) to identify an HRI cohort at two neonatal intensive care units; (2) to identify a control group of infants not meeting HRI criteria; and (3) to measure outpatient and inpatient utilization in both controls using computerized files in a managed care organization. Using California Children's Services criteria as our starting point, we established an HRI definition. From a 1-year birth cohort of 7579 infants at two facilities, we identified 250 infants meeting the HRI definition at two neonatal intensive care units during 1990. We then matched the HRIs with a cohort of 896 randomly selected control newborns (those not meeting the HRI definition). Using organizational computer files and state of California death certificate tapes, we followed these infants until February 28, 1992. We measured the number of hospitalizations, total number of hospital days, and total number of outpatient visits and expressed these outcomes as rates per person-year. We also measured postdischarge mortality. The rate of hospitalization in the HRI group was 6.07 times (95% confidence interval [CI], 4.74-7.77) that in the control group. The utilization of hospital days by the HRI population (hospital days per 1000 person-months) was 13.24 times higher (95% CI, 11.00-16.04). The outpatient visit rate was 1.40 times higher (95% CI, 1.36-1.45) in the HRI population. Our findings in a large managed care organization corroborate previous studies showing that hospitalization rates are significantly higher among HRIs. In our study population, outpatient utilization was significantly higher as well. Our study also demonstrates the feasibility of using computerized files to study outcomes in selected pediatric populations. These methods can be used for epidemiologic studies, interventional trials, and planning for resource allocation.

Specialty care at the crossroads: Electrophysiology practice in the managed-care era

The economics of the managed-care era have declared that there is an over supply of specialists. Especially vulnerable to the changing marketplace are electrophysiologists whose technology is poorly understood by managed-care plans. To be successful, electrophysiology (EP) practices must develop strategies to contend with the new reality. Over the past decade, electrophysiologists at Good Samaritan Hospital (Los Angeles, CA) have worked with the leadership of a large managed-care organization (Family Health Plan [FHP]) to develop guidelines for clinical EP procedures that optimize clinical outcome and cost for EP procedures. The important elements of a successful guideline are that it be a distillation of the best current medical literature and that it be carefully followed and routinely improved. Using the guidelines developed for radiofrequency ablation, FHP found that it was cheaper ($21,166 v $26,448) for FHP patients drug-resistant to supraventricular tachycardia to undergo ablation than to be treated medically. This was for 14 months of care. In addition to the development and implementation of guidelines, a number of factors are important in developing a successful managed-care approach. The physicians should be the “high quality-low cost” provider, with demonstrable excellent clinical outcomes, low complication rates, and competitive pricing. In addition, there must be an efficient short-stay system, with a premium on personal service to the patient and family. Also important is a strong hospital partner as well as sophisticated marketing and contracting support. A new marketplace paradigm is upon us that calls for a change in practice style from that of a decade ago if electrophysiologists are to survive in the managed-care marketplace.

Twin Cities Better Health Restaurant Challenge

To increase the availability of low-fat food and challenge consumers' perceptions, a large managed care organization (MCO) serving over 640,000 members challenged Minneapolis/St. Paul area restaurants to a contest. The objective of the program was to encourage restaurants to offer more low-fat menu items. Competition criteria included ≤9 fat grams per entree and ≤1 fat gram per dessert. Restaurants participating (N=24) received increased visibility through newspaper advertisements, media events, direct member mailings, free point of purchase materials and free Registered Dietitian consulting services and analysis of recipes. Winning restaurants were recognized and cash was donated to the American Heart Association in their name. Coupons for featured menu items were provided to members for use at over 80 participating sites. By rating the menu item(s) and returning the ballot, members of the MCO provided evaluation data and became eligible to win prizes. The average rating of the foods was 4.26 (Likert Scale) with 84% indicating they would order the item again. The restaurants, in follow-up focus groups, indicated increased patron requests for low-fat food since the contest. In conclusion, this program increased both availability and awareness of low-fat food options in our community. Future efforts to increase awareness and availability of healthy low-fat food options clearly may benefit from partnerships between organizations as demonstrated in this program.

The kaleidoscope of general internist careers

As internal medicine residency programs struggle to produce general internists in greater numbers and assure that they are adequately prepared for practice, it is imperative that the graduate medical education system have a clear picture of what competencies will be expected of those entering general internist careers. Feedback from the practicing community and large managed care organizations in Minnesota has made it clear that general internists in that state are functioning in a variety of positions requiring a wide range of skills depending on the practice description, choice of practice setting, and the complement of other primary care providers. General internists functioning in nontraditional careers have special curricular needs. It is imperative that training programs constantly monitor the changing practice environment and stay current on the variety of new generalist career choices to adequately prepare their residents for generalist careers. The graduate medical education enterprise needs to be involved in determining the best teaching strategies for the broad range of ambulatory general medicine competencies and in determining how best to preserve the richness of the medical subspecialty experience critical to the training of excellent general internists.

The effects of organizational structure on primary care outcomes under managed care.

The advent of managed care in the United States brings with it more and larger organizations involved in providing primary care. Studies of organizations in general suggest that large managed care organizations will have difficulty providing high-quality primary care largely because of their complexity and the fragmentation of their work force. Existing data confirm that these organizations have shortcomings in both patient and physician satisfaction. There are few data to indicate whether such organizations can mitigate these problems by saving costs through economies of scale. To offset their inherent weaknesses, large primary care organizations need to ensure patients' accessibility to their physicians, the continuity of the physician-patient relationship, a care environment conducive to a high-quality physician-patient interaction, and the clinical autonomy of physicians. Much additional research needs to be done to further understand these issues.

Managed Care: A Real Solution to Community Health?

Miller and Luft's compilation of research presents a compelling case for the use of group practices and staff models to achieve lower cost and utilization with comparable service quality. Research on newer models has yet to show comparable results. In the second part of the article, the authors speculate on future trends that portend greater purchasing power of employers being focused through fewer but larger managed care firms. In their view, successful firms become larger and gain greater leverage over providers through focused volumes. These large firms will supposedly become smarter, gain economies of scale, and turn the industry into a much more efficient delivery system for medical care thereby avoiding a single-payer revenue-capped, government-imposed system. This line of reasoning requires us to believe that the evolution of managed care on a linear basis will eventually dominate the marketplace in a form that serves the cost and access objectives of the communities, employers, and individuals they serve. With the current infrastructure driving the behaviors of employers, insurers, and providers, we fail to see much reason to believe taking a linear approach will achieve the desired outcome for the community at large. Except for a few examples, none of the large managed care organizations can point to much more than price discounts, coinsurance, and some utilization controls for delivering good or better care at lower cost. And, that is a far cry from a health care organization driven by process improvement and outcome data using more than market power to lower cost without sacrificing quality. Few good examples exist of managed care organizations using their scale or processes to demonstrate best methods for taking care of patients more efficiently or effectively. It appears from the outside that most such firms have achieved success with moderate savings achieved through some worrisome micromanagement techniques and discounts to shadow-price the still higher cost-indemnity systems. If we sense that most of our existing managed care operations are having substantial difficulty in moving into the most desirable models, can we rely on the trends outlined by the authors? As the authors correctly note, the aggregation of our managed care organization into larger-scale organizations has the for doing many things. But, the gap between potential and actual raises many questions about the trends predicted in this article. Some comments on potential trends and current developments include: Centers of excellence. Without the dominance of one big player, it seems more likely that many networks will emerge in each market. In markets with three, four, five, or more networks, will their incentives drive each network to strive for completeness in all services, thus splitting the market and not concentrating it into centers of excellence? In markets where certificate of need (CON) might restrict services to fewer networks, will there be any incentive or requirements for the provider with the single specialized service to offer it to competing networks? Even a cursory examination of our current competitive practices suggests that multiple networks beget proliferation, not focused specialization. Hospital-sponsored managed care plans. The contradictions in the arrangements noted by the authors stem from a provider perspective that views hospitals as revenue centers rather than cost centers. Such perspectives are destructive, yet most of the managed care systems outside the fully integrated models do just this. Some exceptions exist. Henry Ford Health System in Detroit is a good example. Humana's failure to tie managed care and hospitals together along with others may be in the tactical execution rather than in any ultimate contradiction of the organizational concept. A host of failures and errors that teach us little as to how to redefine these self-defeating provider perspectives. …