Managed Care Controls Research Articles

Generic-to-branded drug switch-back patterns: exploratory analysis and insights from the statin class

Objectives This paper analyses generic-to-branded drug switch-back patterns in the statin class. Methods Utilizing LifeLink™ Anonymized Patient Level Data (APLD) from IMS Health, 17.3 million unique treated patients over a 2-year period from July 2006 to June 2008 were analysed. Switch-backs to branded drugs were analysed for patients who started on a branded drug and were switched to a generic statin, or for patients who started therapy on a generic drug. Key findings A total of 538 000 patients, or 3.1% of the total number of treated patients, engaged in switch-backs, of which 69 000 and 469 000 patients are bioequivalent and therapeutic switch-backs, respectively. Excluding 9.7 million patients never on generic drugs, 7.1% of the remaining 7.6 million patients engaged in switch-backs. Switch-back patterns increased with greater patient health risk such as increasing age and co-morbidities. Higher patient doses of simvastatin increased switch-back rates, from about 10% at the 5 and 10 mg doses to 16% at the 80 mg dose. Among switch-back patients, 37% had high cardiovascular risk based on the number of co-morbidities. Switch-backs increased with physician specialty status. Conclusions Managed care controls play a significant role in encouraging initial brand-to-generic substitution which in turn results in switch-back patterns for some classes of patients. Future research considerations and policy implications are discussed. The results suggest that while generic drugs seem to be as good as branded drugs most of the time, this may not always be true. Thus, a universal policy approach mandating generic utilization for all patients, particularly when driven on purely cost grounds, is not appropriate.

Managed care and patient ratings of the quality of specialty care among patients with pain or depressive symptoms.

BackgroundManaged care efforts to regulate access to specialists and reduce costs may lower quality of care. Few studies have examined whether managed care is associated with patient perceptions of the quality of care provided by physician and non-physician specialists. Aim is to determine whether associations exist between managed care controls and patient ratings of the quality of specialty care among primary care patients with pain and depressive symptoms who received specialty care for those conditions.MethodsA prospective cohort study design was conducted in the offices of 261 primary physicians in private practice in Seattle in 1997. Patients (N = 17,187) were screened in waiting rooms, yielding a sample of 1,514 patients with pain only, 575 patients with depressive symptoms only, and 761 patients with pain and depressive symptoms. Patients (n = 1,995) completed a 6-month follow-up survey. Of these, 691 patients received specialty care for pain, and 356 patients saw mental health specialists. For each patient, managed care was measured by the intensity of managed care controls in the patient's health plan and primary care office. Quality of specialty care at follow-up was measured by patient rating of care provided by the specialists. Outcomes were pain interference and bothersomeness, Symptom Checklist for Depression, and restricted activity days.ResultsThe intensity of managed care controls in health plans and primary care offices was generally not associated with patient ratings of the quality of specialty care. However, pain patients in more-managed primary care offices had lower ratings of the quality of specialty care from physician specialists and ancillary providers.ConclusionFor primary care patients with pain or depressive symptoms and who see specialists, managed care controls may influence ratings of specialty care for patients with pain but not patients with depressive symptoms.

Changes in the Quality of Care for Bipolar I Disorder During the 1990s

Changes in the Quality of Care for Bipolar I Disorder During the 1990s

Managed care, physician job satisfaction, and the quality of primary care.

To determine the associations between managed care, physician job satisfaction, and the quality of primary care, and to determine whether physician job satisfaction is associated with health outcomes among primary care patients with pain and depressive symptoms. Prospective cohort study. Offices of 261 primary physicians in private practice in Seattle. We screened 17,187 patients in waiting rooms, yielding a sample of 1,514 patients with pain only, 575 patients with depressive symptoms only, and 761 patients with pain and depressive symptoms; 2,004 patients completed a 6-month follow-up survey. For each patient, managed care was measured by the intensity of managed care controls in the patient's primary care office, physician financial incentives, and whether the physician read or used back pain and depression guidelines. Physician job satisfaction at baseline was measured through a 6-item scale. Quality of primary care at follow-up was measured by patient rating of care provided by the primary physician, patient trust and confidence in primary physician, quality-of-care index, and continuity of primary physician. Outcomes were pain interference and bothersomeness, Symptom Checklist for Depression, and restricted activity days. Pain and depression patients of physicians with greater job satisfaction had greater trust and confidence in their primary physicians. Pain patients of more satisfied physicians also were less likely to change physicians in the follow-up period. Depression patients of more satisfied physicians had higher ratings of the care provided by their physicians. These associations remained after controlling statistically for managed care. Physician job satisfaction was not associated with health outcomes. For primary care patients with pain or depressive symptoms, primary physician job satisfaction is associated with some measures of patient-rated quality of care but not health outcomes.

Managed Care and Patient-Rated Quality of Care from Primary Physicians

The aim is to determine the associations between managed care controls and patient-rated quality of care from primary physicians. In a prospective cohort study, 17,187 patients were screened in the waiting rooms of 261 primary care physicians in the Seattle metropolitan area (1996-1997) to identify 2,850 English-speaking adult patients with depressive symptoms and/or selected pain problems. Patients completed 6-month follow-ups to rate the quality of care from their primary physicians. The intensity of managed care was measured for each patient's health plan, primary care office, and physician. Regression analyses revealed that patients in more managed plans and offices had lower ratings of the quality of care from their primary physicians. Managed care controls targeting physicians were generally not associated with patient ratings.

Incorporating life care planning concepts in case management

Now more than ever, the fabric of our health care system is fraying from challenges that are closing in and demanding solutions. After years of managed care controls, we have health care inflation in the double digits, the percentage of the gross domestic product that goes to health-related issues continues to rise, insurance companies are predictably responding to the crisis with increases in premiums to employers, and employers are shifting more of the burden for these increases onto the employee with higher copayments, higher deductibles, limited benefits, and limited choices.

Retaining medical directors in community health centers. The importance of administrative relationships.

Physician retention has become a critical issue for maintaining the success of today's health care organizations. With many external factors--increasing malpractice premiums, lower reimbursement rates, and managed care controls--driving physicians out of the practice, it is imperative to understand how the internal functions of the organization can help maintain satisfaction in the workplace and prevent physicians from leaving (Reece, 2000; Taylor, 2002). This is especially important in Community and Migrant Health Centers (C/MHCs), federally supported health clinics providing care to low-income and uninsured patients in medically underserved communities and neighborhoods. In this study, we examine the medical directors' roles and responsibilities, their relationships with the C/MHC administrators, and whether these impact satisfaction and, ultimately retention in the centers.

Managed care, access to specialists, and outcomes among primary care patients with pain.

To determine whether managed care controls were associated with reduced access to specialists and worse outcomes among primary care patients with pain. Patient, physician, and office manager questionnaires collected in the Seattle area in 1996-1997, plus data abstracted from patient records and health plans. A prospective cohort study of 2,275 adult patients with common pain problems recruited in the offices of 261 primary care physicians in Seattle. Patients completed a waiting room questionnaire and follow-up surveys at the end of the first and sixth months to measure access to specialists and outcomes. Intensity of managed care controls measured by plan managed care index and benefit/cost-sharing indexes, office managed care index, physician compensation, financial incentives, and use of clinical guidelines. A financial withhold for referral was associated with a lower likelihood of referral to a physician specialist, a greater likelihood of seeing a specialist without referral, and a lower patient rating of care from the primary physician. Otherwise, patients in more managed offices and with greater out-of-network plan benefits had greater access to specialists. Patients with more versus less managed care had similar health outcomes, but patients in more managed offices had lower ratings of care provided by their primary physicians. Increased managed care controls were generally not associated with reduced access to specialists and worse health outcomes for primary care patients with pain, but patients in more managed offices had lower ratings of care provided by their primary physicians.

The Effects of Managed Care on Medical Referrals and the Quality of Specialty Care

This paper analyzes the role of referrals in the provision of surgical services. Primary physicians in managed care control patient access to specialists, while referrals in traditional insurance plans are less constrained. The traditional, fee–for–service insurance market is shown to achieve appropriate incentives for high quality care. In contrast, physicians with bad reputations may not lose HMO’s referrals, owing to differences in incentives to cut costs. Empirically, we find that managed care may protect a physician whose reputation has been damaged by providing a source of referrals when shunning occurs in the FFS sector following a malpractice claim.

Provider Selection, Bargaining, and Utilization Management in Managed Care

Managed care controls cost through a combination of provider selection, bargaining, and utilization management. Provider selection will reduce expenditures if patients are funneled to efficient providers. Bargaining will reduce expenditures through lower rates. Utilization management will reduce expenditures if providers reduce treatment intensity due to monitoring. We estimate that about 30% of the reduction in inpatient expenditures in a mental health carve‐out was due to provider selection, 5% was due to bargaining, and the remaining 65% was due to utilization management. We find that both the provider selection and utilization management effects were likely to be welfare improving.

Academic pediatric departments, government agencies, and children with special health care needs

Academic pediatric departments, government agencies, and children with special health care needs

Controversy Accompanies Proposal For Major AMA Reorganization

Controversy Accompanies Proposal For Major AMA Reorganization

Can Managed Care Control its Costs if Patients are Allowed Free Choice of Consultant Specialist?

Can Managed Care Control its Costs if Patients are Allowed Free Choice of Consultant Specialist?

Parity for mental health and substance abuse care under managed care.

BACKGROUND: Parity in insurance coverage for mental health and substance abuse has been a key goal of mental health and substance abuse care advocates in the United States during most of the past 20 years. The push for parity began during the era of indemnity insurance and fee for service payment when benefit design was the main rationing device in health care. The central economic argument for enacting legislation aimed at regulating the insurance benefit was to address market failure stemming from adverse selection. The case against parity was based on inefficiency related to moral hazard. Empirical analyses provided evidence that ambulatory mental health services were considerably more responsive to the terms of insurance than were ambulatory medical services. AIMS: Our goal in this research is to reexamine the economics of parity in the light of recent changes in the delivery of health care in the United States. Specifically managed care has fundamentally altered the way in which health services are rationed. Benefit design is now only one mechanism among many that are used to allocate health care resources and control costs. We examine the implication of these changes for policies aimed at achieving parity in insurance coverage. METHOD: We develop a theoretical approach to characterizing rationing under managed care. We then analyze the traditional efficiency concerns in insurance, adverse selection and moral hazard in the context of policy aimed at regulating health and mental health benefits under private insurance. RESULTS: We show that since managed care controls costs and utilization in new ways parity in benefit design no longer implies equal access to and quality of mental health and substance abuse care. Because costs are controlled by management under managed care and not primarily by out of pocket prices paid by consumers, demand response recedes as an efficiency argument against parity. At the same time parity in benefit design may accomplish less with respect to providing a remedy to problems related to adverse selection.

Parity for mental health and substance abuse care under managed care

Background: Parity in insurance coverage for mental health and substance abuse has been a key goal of mental health and substance abuse care advocates in the United States during most of the past 20 years. The push for parity began during the era of indemnity insurance and fee for service payment when benefit design was the main rationing device in health care. The central economic argument for enacting legislation aimed at regulating the insurance benefit was to address market failure stemming from adverse selection. The case against parity was based on inefficiency related to moral hazard. Empirical analyses provided evidence that ambulatory mental health services were considerably more responsive to the terms of insurance than were ambulatory medical services. Aims: Our goal in this research is to reexamine the economics of parity in the light of recent changes in the delivery of health care in the United States. Specifically managed care has fundamentally altered the way in which health services are rationed. Benefit design is now only one mechanism among many that are used to allocate health care resources and control costs. We examine the implication of these changes for policies aimed at achieving parity in insurance coverage. Method: We develop a theoretical approach to characterizing rationing under managed care. We then analyze the traditional efficiency concerns in insurance, adverse selection and moral hazard in the context of policy aimed at regulating health and mental health benefits under private insurance. Results: We show that since managed care controls costs and utilization in new ways parity in benefit design no longer implies equal access to and quality of mental health and substance abuse care. Because costs are controlled by management under managed care and not primarily by out of pocket prices paid by consumers, demand response recedes as an efficiency argument against parity. At the same time parity in benefit design may accomplish less with respect to providing a remedy to problems related to adverse selection. © 1998 John Wiley & Sons, Ltd.

Can Managed Care Control Costs?

Can Managed Care Control Costs?