Managed Care Insurance Research Articles

Breast Cancer in Male Adolescents and Young Adults.

Breast cancer is one of the most common cancers in female adolescent and young adults (AYA; age 15-39years). However, few data exist detailing either in situ or invasive breast cancer in male AYAs. All male AYA breast cancer cases were identified in the National Cancer Data Base (1998-2010). Demographics, tumor, and treatment predictors of overall survival (OS) were determined for both patients with in situ and invasive tumors. Of 677 male AYAs, 122 patients (18%) had in situ breast cancer, while 555 patients (82%) were found to have invasive breast cancer. Compared to in situ breast cancer, invasive breast cancer in male AYAs was less likely to occur in patients with private or managed care insurance (p=0.003) or <20years of age (p=0.028). In patients with invasive breast cancer, lower OS was associated with age ≤25years (p=0.006), black race (p=0.018), not having Medicaid/Medicare/government/military insurance (p<0.001), the lowest socioeconomic status (p=0.001), higher overall stage (p<0.001), T stage (p<0.001), nodal stage (p<0.001), and M stage (p<0.001), as well as not having any surgery (p<0.001) or nodal evaluation at surgery (p<0.001). After controlling for competing factors, only age ≤25years (hazard ratio 3.064, 95% confidence interval 1.216-7.720) and not having nodal evaluation (hazard ratio 3.070, 95% confidence interval 1.423-6.626) predicted decreased OS. Younger age and not having nodal evaluation at the time of surgery are associated with decreased OS in AYA male patients with invasive cancer. This highlights the need to perform axillary node sampling through sentinel node biopsy at the time of mastectomy in these young male patients.

Low-Cost Generic Program Use by Medicare Beneficiaries: Implications for Medication Exposure Misclassification in Administrative Claims Data.

BACKGROUND: Administrative claims data are used for a wide variety of research and quality assurance purposes; however, they are prone to medication exposure misclassification if medications are purchased without using an insurance benefit. Low-cost generic drug programs (LCGPs) offered at major chain pharmacies are a relatively new and sparsely investigated source of exposure misclassification. LCGP medications are often purchased out of pocket; thus, a pharmacy claim may never be submitted, and the exposure may go unobserved in claims data. As heavy users of medications, Medicare beneficiaries have much to gain from the affordable medications offered through LCGPs. This use may put them at increased risk of exposure misclassification in claims data. Many high-risk medications (HRMs) and medications tracked for adherence and utilization quality metrics are available through LCGPs, and exposure misclassification of these medications may impact the quality assurance efforts reliant on administrative claims...

Choosing the benefit package from the BPJS program: Findings from CHAT experiment

Aim: This study aims to design the benefit–package composition of health insurance benefits in accordance with the priority of the needs of the participants of BPJS and the amount of their willingness to pay the premium rate.Background: This design aimed at ensuring the relevance of the benefit packages to beneficiary communities, so the implementation of the design is expected to increase peoples’ contributions in joining BPJS for health program.Method: This study use Choosing Health plans All Together (CHAT) as a method for design the benefit–package composition. The CHAT exercise enabled participants to choose from nine benefit type and for each benefit type, the participants could choose three coverage levels, i.e. basic, medium, and high. There were 246 participants as a sample for CHAT exercise. The sample size was calculated as optimal based on a 5% margin of error and a 95% confidence interval and randomly selected based on two-stage cluster sampling method.Result: According to their willingness to pay, a sample size of 246 participants was divided into three groups. A total of 72 (29.3%) participants chose a premium rate at IDR 59 500 and called group 1 participants, 84 (34.1%) participants chose a premium rate at 42 500 IDR and called group 2 participants, and 90 (36.6%) participants chose a premium rate at 25 500 IDR and called group 3 participants. Basically, the CHAT experiment results for group 1 until group 3 of the participants can be divided into two types of package, i.e. package with maternity benefit and package without maternity benefit. As example, for group 1 of participant, package with maternity benefit consists of hospitalization (medium), ICU (high), surgery (high), doctor (high), and maternity (high), whereas package without maternity benefit for group 1 of participant consists of hospitalization (high), ICU (high), surgery (high), doctor (high), tests (high) and dental care (high).Conclusion: This study resulted that CHAT experiment can help groups of individuals to identify their preferred health insurance package under cost constraints to demonstrate various managed care insurance packages that are likely to be acceptable to uninsured individuals.

Kesesuaianbenefit Package yang Diterima oleh Pesertaasuransi di Pusat Layanan Kesehatan Universitas Airlangga

ABSTRACTBenefit package provided for policyholderis expected to be in accordance with policyholder’s expectations. This research aimed to evaluate the conformity of the benefit package received by policyholder in Airlangga Health Care Center.This was descriptive study with cross sectional design. Data analysis quantitative with observational data.The population was all employees of Airlangga Health Care Center. The results of this study show that the total cost of health care in the PLK-UA in 2009 amounted to IDR 1.232.974.580, while the income was IDR 1.309.680.000. Based on the result, the calculation shows that the benefit package received by policyholders is worth the premium paid in the amount of IDR 60.000 per year.These conclutionis the implementation managed care insurance system that provides maximum service to policyholders by means of giving back the premium thathas been paid by the policyholders in the form of benefit package or development of facilities and infrastructure. However,revised service package provided by Airlangga Health Care Centershould be reconsidered in order to meet the expectations of policyholders.Keywords:benefit package, health insurancepremium, policyholders

Economic burden of brain metastases among patients with metastatic melanoma in a USA managed care population.

Malignant melanoma patients frequently relapse with metastases in the brain, making it the third most common cancer-causing brain metastases in the USA. Management of brain metastases remains challenging because of the rapid progression of disease and ineffectiveness of conventional therapies. This retrospective study, with a 'pre/post' design, quantifies the economic burden of brain metastases among melanoma patients in the USA. A large managed-care insurance claims database (2000 Q1-2011 Q3) was used to identify patients with melanoma and brain metastases. The preperiod was defined as the 6 months before the index date (diagnosis of first observed brain metastases) and postperiod as the period following the index date up to 12 months. All-cause and brain metastasis-related healthcare resource utilization and healthcare costs were compared on a per-patient-per-month (PPPM) basis between preperiods and postperiods. The study included 6076 patients (mean age 63.4 years); 57.6% were men. Significant differences (P<0.0001) were observed between the postperiods and preperiods in the mean all-cause and brain metastasis-related PPPM hospitalizations and emergency department and outpatient visits. Significant postperiod versus preperiod differences were also observed in the PPPM mean (standard error) all-cause healthcare costs [total: $14 489 ($231) vs. $7277 ($116); inpatient: $6330 ($195) vs. $1900 ($69); outpatient: $6609 ($102) vs. $4449 ($79); P<0.0001 for all] and brain metastasis-related costs [total: $6542 ($145) vs. $1933 ($62); inpatient: $2976 ($118) vs. $472 ($39); outpatient: $3451 ($76) vs. $1413 ($47); P<0.0001 for all]. Radiotherapy was the most common treatment. The economic burden associated with brain metastases in melanoma is significant and underscores the need for newer therapies to improve outcomes in these patients.

Are there disparities in the utilization of sentinel lymph node biopsies in patients with breast cancer?

117 Background: Racial disparities in outcomes continue to persist amongst breast cancer (BC) patients (pts). Standard of care for the surgical evaluation of early BC has changed from axillary lymph node dissection being recommended for axillary staging to sentinel lymph node biopsy (SLNB) for clinically node-negative pts. SLNB, however, can be deferred if findings would not alter treatment plans. The goal of this study is to determine if SLNB rates differ by race, age, insurer, community vs academic setting or surgeon. Causes contributing to disparities will be considered. Methods: Pts undergoing primary surgery for early stage BC from 2010-2011 at our academic teaching hospital and two affiliated community medical centers were identified from the tumor registry. Data abstracted included demographics, insurance type, medical center and surgeon. For pts without SLNB, clinical information was confirmed with medical record review. Unadjusted comparison of factors for pts who did and did not have SLNB was evaluated with a t-test or chi square test. Logistic regression modeling assessed significance of demographic and clinical factors predicting SLNB. Results: 499 pts were identified; 114 (23%) were black, 373 (75%) white, and 12 (2%) others/unknown race. SLNB was performed in 443 (89%) of total pts, without racial differences (86% of black and 89% of white pts (p=0.31) had SLNB). Average age of pts who had SLNB was younger (60.4) than those who did not (76.3) (p&lt;0.01). As compared to those with managed care insurance (97%) or Medicaid (91%), only 78% of Medicare pts had SLNB (p&lt;0.01). There was no statistical difference in SLNB rates between academic and community medical centers or by surgeon. Chart review determined that the standard of care was met in 55/56 pts who did not have SLNB; reasons for no SLNB include advanced age (range 79-95), in-breast recurrences, and positive nodes pre-operatively. Conclusions: Utilization rates of SLNB did not differ between black and white BC pts. Differences were seen based on age and insurer. Although only 89% of pts had SLNB, careful evaluation for reasons reveals medically appropriate treatment in almost all cases. These results suggest cautionary interpretation of large database findings.

Advancing Research in the Era of Healthcare Reform: The 19th Annual HMO Research Network Conference, April 16-18, 2013, San Francisco, California

Healthcare system transformation has pursued higher quality, more affordable healthcare from the popularization of health maintenance organizations (HMOs) in the 1970s, through the innovations in structure and management of the 1990s, to the current-day challenge of extending healthcare coverage to previously uninsured groups as partially conceptualized in the Patient Protection and Affordable Care Act (PPACA) toward Accountable Care Organizations (ACOs). Census 2010 reported that 17% of Americans had no insurance whatsoever, 18% were publicly insured,1 and the remaining 65% were privately insured. Overall, approximately 1 in 4 Americans is enrolled in an HMO, including Medicare HMO options. Research on persons covered by managed care insurance and integrated delivery systems is needed to round out our understanding of how people use healthcare and how their health status relates to that usage. These are the middle class Americans, the working well, who are not well represented in federal programs. Groups commonly examined by health services researchers include Medicaid beneficiaries (impoverished, mostly children), Medicare beneficiaries (older or disabled persons), and Veteran’s Administration patients (disabled, impoverished, tied to military recruitment trends, mostly male). Other major sources of health data are primarily survey-based (such as the National Ambulatory Medical Care Survey on outpatient care) or topically focused (Surveillance Epidemiology and End Results on cancer, Health Cost and Utilization Project on inpatient experiences) and therefore lacking in comprehensiveness and in detail regarding specific procedures, medications, and diagnoses received. These factors—population and data quality—spurred the development of the HMO Research Network (HMORN) and its Virtual Data Warehouse (VDW), a clinical records-based data resource on insured persons. Now in its 19th year, the HMORN held its annual meeting in San Francisco, April 16–18, 2013, hosted by Kaiser Permanente of Northern California with Dr. Alan Go as Chair. We are now in the era of healthcare reform. Cost containment continues to pressure development of efficient care delivery and payment structures, with quality of care and patient experience as equal goals in the “Triple Aim”.2 In the past two years, changes enacted via the American Recovery and Reinvestment Act-funded Health Information Technology for Economic and Clinical Health electronic medical records adoption mandate (beginning in 2011), expansion initiatives for Medicaid, rural and other underserved populations (as of March 2012), and economic market forces, in general, have continued to shape both clientele-served and cost reimbursement schemas. This evolution has led healthcare systems to ask, why do people come through our doors? Who chooses not to return? What do we have to do as a system to provide high quality care at a sustainable price, engendering excellent patient satisfaction? These challenges informed the theme of the 2013 HMO Research Network Conference, “Advancing Research in the Era of Healthcare Reform.”

Abstract 216: Identification of Secondary Cardiovascular Risk in Patients with Familial Hypercholesterolemia after Coronary Artery Disease from a US Database

Background: Despite extensive research on health impact of hypercholesterolemia (HC), the cardiovascular (CV) risk in pts with familial hypercholesterolemia (FH) is not well understood. This study was performed to identify the secondary CV risk in pts with FH after coronary artery disease (CAD). Methods: Statin users between Jan 2004 and Jun 2010 were identified from the US IMPACT health insurance claims database. Two groups of FH pts with CAD were identified according to Simon Broome criteria: High-LDL FH (HFH) LDL-C ≥200 mg/dL; Moderate-LDL FH (MFH) 190≤ LDL-C &lt;200 mg/dL. A non-FH cohort was identified as HC+ CAD, with 100&lt; LDL-C &lt;190 mg/dL. Secondary CV event rates (including stoke, myocardial infarction, unstable angina) were assessed in the 3 cohorts against the most recent LDL-C value prior to the CV event. Results: Secondary CV event rate was 7.5/100 pt-yrs in HFH (n=1277, age 59 yrs, 49% male, mean baseline LDL-C 189 mg/dL), 6.1/100 pt-yrs in MFH (n=549, 59 yrs, 48% male, LDL-C 149 mg/dL) and 4.6/100 pt-yrs in Non-FH (n=4484, 61 yrs, 60% male, LDL-C 126 mg/dL). CV event rate increased 63% in HFH (rate ratio (RR)=1.63, p&lt;0.01) and 33% in MFH (RR=1.33, p=0.02) compared to the Non-FH cohort. Furthermore, CV risk continued to rise with LDL-C across all 3 cohorts (8% per every additional 20 mg/dL LDL-C, p&lt;0.01), even in the HFH cohort that had the highest base CV event rate (5% per 20 mg/dL LDL-C, p=0.02). Older age, male gender and more comorbidities were associated with increased CV risk, while ezetimibe+statin and atorvastatin were associated with a lower CV risk compared to simvastatin. Conclusions: Secondary CV event risk increased with LDL-C levels across the FH and non-FH cohorts identified from the US managed care insurance claims database. Compared with non-FH, FH pts are at a significantly higher CV risk. CV risk continues to rise with LDL-C levels even within the high LDL FH cohort. These findings suggest a prominent clinical gap especially in the high LDL FH pts that require appropriate identification for effective therapy.

Costs Associated with Intravenous Cancer Therapy Administration in Patients with Metastatic Soft Tissue Sarcoma in a US Population

Background. The most common chemotherapies in metastatic soft tissue sarcoma (mSTS) require intravenous (IV) administration. This often requires patients to make multiple outpatient visits per chemotherapy cycle, possibly impeding patients' daily activities and increasing caregiver burden and medical costs. This study investigated costs associated with IV cancer therapy administration in mSTS from the payer perspective of the health care system. Patients and Methods. From the Experian Healthcare database, 1,228 mSTS patients were selected. Data were analyzed on outpatient visits during 2005–2012 involving IV cancer therapy administration. Costs were estimated on a per patient per visit (PPPV) and per patient per month (PPPM) basis. Results. The mean (median) cost of IV therapy was $2,427 ($1,532) PPPV and $5,468 ($4,310) PPPM, of which approximately 60% was IV drug costs. IV administration costs averaged $399 PPPV and $900 PPPM, representing 16.5% of total visit costs. Anthracycline and alkylating-agents-based therapies had the highest PPPV and PPPM IV administration costs, respectively (mean $479 and $1,336, resp.). Patients with managed care insurance had the highest IV administration costs (mean $504 PPPV; $1,120 PPPM). Conclusions. IV administration costs constitute a considerable proportion of the total costs of receiving an IV cancer therapy to treat mSTS.

Practice-Based Evidence: 45 Years of Psychotherapy’s Effectiveness in a Private Practice

Of 2,259 patients seen during 45 years of private practice, outcome data was produced for 1,599 cases. The mean (SD) number of sessions per case was 18.82 (29.89). The dropout rate was 18.76%. Of all treated cases with outcome data 4 (0.25%) were rated as Much Worse; 11 (0.69%), Worse; 497 (31.08%), No Change from Intake; 546 (34.15%), Improved; and 541 (33.83%), Much Improved. The mean (SD) pre-/post-treatment effect size (ES) was 1.90 (1.61), the median was 1.62, and the range was from -2.91 to +15.22. Patients and parents of minors rated outcomes more positively than the therapist did. Outcome varied significantly across diagnostic categories. There was a significant, positive relationship in length of treatment and outcome. The therapist's effectiveness did not improve across the years. Years with the largest patient caseloads or the greatest proportion of patients with managed-care insurance tended to show the poorest outcomes.

Have We Expanded the Equitable Delivery of Postmastectomy Breast Reconstruction in the New Millennium? Evidence from the National Cancer Data Base

Studies examining patterns of cancer care before 2000 have shown underuse of postmastectomy breast reconstruction as well as racial and socioeconomic disparities in its delivery. These findings prompted legislation designed to broaden use at the turn of the millennium. However, little is known about trends in these findings over the past decade. Patients who underwent mastectomy for stage 0 to III breast cancer between 1998 and 2007 (n = 452,903) were studied using the National Cancer Data Base to evaluate trends in the receipt of immediate and early delayed breast reconstruction. Those who underwent mastectomy between 1998 and 2000 (n = 150,177) and between 2005 and 2007 (n = 123,518) were compared using logistic regression to identify factors influencing the use of breast reconstruction and how they changed over time. The use of postmastectomy breast reconstruction increased from 13% to 26% from 1998 to 2007. This increase was statistically significant in almost all patient subsets. Independent factors associated with breast reconstruction included age less than 50 years old; higher census-derived household income; private or managed care insurance; non-African American race; and treatment in an academic hospital setting. Treatment in an academic hospital and higher income became stronger predictors of breast reconstruction over the study period, while age became less of a predictor. Although the use of breast reconstruction has increased from 1998 to 2007, it is still underused among many patient populations. Furthermore, racial and socioeconomic disparities in its delivery have persisted or widened. Additional effort is necessary to broaden the use of breast reconstruction and to ensure equitable access to it.

Reply to the letter to the editor “Freedom of choice”

We thank Dr. Gnadinger for raising the issue of freedom of choice, which would certainly be of great interest to debate within the framework of the current Swiss healthcare system. Current chronic care models and concepts (such as patient empowerment, shared decision-making and patientcentred care) place the emphasis on patients’ needs, values and roles. In addition, patients need to be well informed if they are to be appropriately involved in their care. Patients cannot be considered “passive recipients of care but as live actors – replete with hopes, anxieties, desires, …” [1]. Knowing individuals’ opinions, be they current or future patients, is therefore important. This may be particularly true in Switzerland, in view of the opportunities for popular referenda and initiatives, which may prevent policymakers from implementing changes in the healthcare system. We would remind readers here that the point of our article is not to state a position regarding the ongoing discussions on managed care in Switzerland, but rather to describe, objectively, the answers Swiss respondents gave to the question (included in the Swiss Health Survey) “How important is it for you to be able to choose the specialist you would like to consult?”, as well as to determine the factors characterising individuals who deemed the freedom of choice to be very important. Results showed that, in 2007, 45% of respondents found this choice important. They also showed that those more likely to value freedom of choice were women, in middle/senior executive positions, with an ordinary insurance scheme, reporting ≥2 chronic conditions, presenting poorer subjective health or reporting ≥2 outpatient visits. If freedom to choose specialists were restricted in the healthcare system, Swiss respondents would need to be convinced that an appropriate policy decision was taken. This is important since Switzerland has a long tradition of unrestricted access to healthcare providers, of citizens satisfied with their healthcare system despite ongoing high healthcare expenditures, and good healthcare indicators [2, 3]. Switzerland faces the challenge of tackling the rising burden of chronic diseases. Good information, in addition to appropriate incentives, are needed to motivate Swiss citizens to accept and support the development of new care models such as those currently discussed as part of the revision of the Federal Health Law (managed care – integrated care models). Appropriate incentives for individuals to enroll in managed care insurance schemes (to avoid risk selection by health insurance companies) are also key for their wider use. Future Swiss studies must show that these models offer a way not only to limit healthcare costs, but also to improve healthcare quality.

Comparative Effectiveness, Cost, and Utilization of Radical Prostatectomy among Young Men within Managed Care Insurance Plans

BackgroundCosts and benefits of emerging prostate cancer treatments for young men (age < 65 years) in the United States are not well understood. We compared utilization, clinical outcomes, and costs between two types of radical prostatectomy (RP)—minimally invasive prostatectomy (MIRP) and retropubic prostatectomy (RRP)—among young patients. MethodsWe extracted from LifeLink Health Plan Claims Database, a commercial claims database, information on 10,669 patients receiving either MIRP or RRP between 2003 and 2007. In unadjusted analyses, we used chi-square tests to compare clinical outcomes and nonparametric bootstrapping method to compare costs between the MIRP and RRP groups. We applied logistic, Cox proportional hazard, and extended estimation equation methods to examine the association between surgical modality and perioperative complications, anastomotic stricture, and costs while controlling for age, comorbidity, and health plan characteristics. ResultsThe percentage of prostatectomies performed as MIRP increased from 5.7% in 2003 to 50.3% in 2007. Patients with more comorbidity were more likely to undergo RRP than MIRP. Compared with the RRP group, the MIRP group had a significantly lower rate of perioperative complications (23.0% vs. 30.4%; P < 0.001) and a lesser tendency for anastomotic strictures (hazard ratio 0.42; 95% CI 0.35–0.50) within the first postoperative year but had higher hospitalization costs ($19,998 vs. $18,424; P < 0.001) despite shorter hospitalizations (1.7 days vs. 3.1 days; P < 0.001). Similar findings were reported in the subgroup analysis of patients with comorbidity score 0. ConclusionMIRP among nonelderly patients increased substantially over time. MIRP was found to have fewer complications. Lower costs of complications appeared to have offset higher hospitalization costs of MIRP.

P1-11-02: Racial/Ethnic Differences in Adjuvant Trastuzumab Receipt for Women with Breast Cancer within the National Comprehensive Cancer Network.

Abstract Background Racial/ethnic disparities in breast cancer care are well documented. Although adjuvant trastuzumab has been shown to improve disease outcomes for women with Human Epidermal Growth Factor Receptor 2 (HER2)-positive cancers, the ‘real world’ utilization and toxicity of adjuvant trastuzumab are unknown. Because therapy involves one year of treatment and the costs of treatment are high, a risk for treatment disparity exists. We examined differences in receipt and completion of adjuvant trastuzumab by race/ethnicity, education, employment, and insurance for women diagnosed with HER2−positive breast cancer. Methods Using the National Comprehensive Cancer Network (NCCN) Breast Cancer Outcomes Database, we identified 1,146 women with stage I-III HER-2 positive breast cancer who presented to participating NCCN institutions during 2005–2008. In multivariable logistic analyses, we assessed the effect of race/ethnicity on the likelihood of trastuzumab therapy, and among women who initiated trastuzumab, the likelihood of completing ≥ 270 days of therapy, adjusting for center, diagnosis year, age, insurance, comorbidity, education, employment, and tumor characteristics. We also examined reasons for discontinuation of therapy among those who stopped treatment prematurely. Results Among patients eligible for this analysis, 75% women were Caucasian, 9% were African-American, and 9% were Hispanic. Most women had managed care insurance (71%) and were employed/student (52%). About one-third (36%) had a college degree and 39% had a high school education or less. Overall, most women (82%) received neo/adjuvant trastuzumab and there were no racial/ethnic differences in receipt of therapy (adjusted odds ratio [OR] 1.11, 95% confidence interval [CI] .72-1.71 for African-American and OR 1.39, 95% CI .76-2.54 for Hispanic, versus Caucasian women). Among the 769 women who initiated neo/adjuvant trastuzumab and had ≥ 365 days of follow-up, 84% completed ≥ 270 days of trastuzumab. Rates of completion were lower for African-American (72%) and Hispanic (82%) women than Caucasian women (85%). In adjusted analyses, African-American women but not Hispanic women had lower odds of completing therapy compared with Caucasian women (OR .45, 95% CI .29-.70, p=0.0003). Indemnity insurance (versus managed care) was associated with lower odds of trastuzumab completion, as was having a high school education or less (versus college education). Among the 123 women who did not complete trastuzumab, 26% stopped early for toxicity, and this occurred more frequently for African-American women than Caucasian women (50% vs. 21%), but small sample precluded a meaningful test for statistical significance. Conclusion: Compared with Caucasian women, African-American women had similar rates of initiation of adjuvant trastuzumab but much lower rates of completion that were not explained by differences in education, employment, or insurance. Because of the significant benefits conferred by adjuvant trastuzumab therapy for HER2−positive breast cancer, interventions to assure completion of therapy could lead to improved outcomes. Further exploration of racial differences in toxicity and tolerance of therapy are also warranted. Citation Information: Cancer Res 2011;71(24 Suppl):Abstract nr P1-11-02.

The effects of institutional change on geographic variation and health services use in the USA

This paper examines the impact of institutional change on patient care. Using panel data on obstetric deliveries from the state of California in the United States between 1983 and 2001, it develops and tests hypotheses predicting impacts of three features of institutional change—managed care insurance, changing professional controls and public attention to cost-control practices—on cesarean use and geographic variation in cesarean deliveries. It finds that managed care insurance promotes the diffusion of cost-effective patient care practices, reducing cesarean use and increasing variation. I found that over time, managed care patients experience continued lower use and reduced geographic variation as new practices become established. The combined effects of changing professional controls—the growing importance of clinical guidelines—and public attention to cost-control practices also diffuses cost-effective practices, increasing variation and decreasing cesarean use. Cesarean use increases and geographic variation declines in a period of managed care retreat in the late 1990s. The analysis extends prior research by documenting the impact of institutional change on health services use and variation and by suggesting that geographic variation is caused, in part, by the diffusion of new patient care practices.

Reference of and comparison between managed care and traditional medical insurance in America

Managed care insurance is growing into the mainstream health insurance model in the United States. The differences between this and the traditional health insurance lie in their economic model, their autonomy of consumers in their choices of suppliers, their economic risk exposure for clinicians, their effect on utilization review and their impact to clinical decision-making. Managed care can only, in terms of cost constraints, affect or limit the autonomy of medical decision, instead of making decisions in lieu of clinicians. Under managed care, both the professional risk of clinicians and health benefits of consumers are exposed to obvious negative influence. In the meantime, the model is facing growing difficulties in the future for the market itself. In this regard, prudence is required to introduce managed care in China. Key words: United States; Managed care; Traditional health insurance

Trends in Contralateral Prophylactic Mastectomy for Unilateral Cancer: A Report From the National Cancer Data Base, 1998–2007

Several studies have reported an increased rate of contralateral prophylactic mastectomy (CPM) in patients with unilateral breast cancer. This study reports on CPM trends from the American College of Surgeon's National Cancer Data Base (NCDB) diagnosed over a 10-year period. Data about women diagnosed with unilateral breast cancer between 1998 and 2007 undergoing CPM were extracted from the NCDB. Temporal trends were analyzed across patient demographic, tumor, and provider characteristics. Logistic regression models identified characteristics independently associated with use of CPM. A total of 1,166,456 patients, of whom 23,218 patients underwent CPM, were reviewed; use increased from 0.4% in 1998 to 4.7% in 2007 of surgically treated patients. The greatest comparative increases in CPM was among white patients <40years of age residing in high socioeconomic status areas with private or managed care insurance plans and treated at high-volume medical centers in the Midwest region of the country. A greater proportion of patients with in-situ disease undergo CPM compared to invasive disease. Independent factors associated with CPM include patient demographic and socioeconomic factors, tumor stage and histopathology, and provider characteristics. Although an increase in the proportion of surgically treated women undergoing CPM was universally observed across a broad range of patient, biological, and provider factors, the increase was more noticeably associated with patient-related factors rather than tumor or biological characteristics. Further studies are needed to determine why patients seem to choose CPM and whether a survival benefit can be associated with this choice of surgical management.

Access to Care and the Incidence of Endstage Renal Disease Due to Systemic Lupus Erythematosus

Persons with low socioeconomic status have an increased risk of endstage renal disease (ESRD) due to systemic lupus erythematosus (SLE), possibly because of limited access to care. We examined if the incidence of ESRD due to SLE was higher in geographic areas with poorer access to care. In this population-based ecological study, we tested associations between the incidence of ESRD due to SLE and the proportion of hospitalizations with no insurance, Medicaid or managed care insurance, residence in a primary care-provider shortage area or rural area, and rate of hospitalizations for ambulatory care-sensitive conditions, by ZIP code in California in 1999-2004. The incidence of ESRD due to SLE was higher in ZIP codes with higher proportions of hospitalizations with no insurance (r = 0.22, p < 0.0001) or Medicaid (r = 0.21, p < 0.0001), and in ZIP codes with higher rates of hospitalizations for ambulatory care-sensitive conditions (r = 0.23, p < 0.0001). In multivariate analyses, incidences were higher in ZIP codes with higher proportions of hospitalizations with Medicaid (p < 0.0001) and higher rates of hospitalizations for ambulatory care-sensitive conditions (p = 0.06), independent of the socioeconomic status of the ZIP code residents. The incidence of ESRD due to SLE is higher in areas with higher proportions of residents who have public insurance and higher rates of avoidable hospitalizations, suggesting that limited access to care may contribute to this complication of SLE.

Gender and Ethnicity Group Differences Among Substance Abuse Treatment Clients Insured Under Managed Care

This longitudinal study of substance abuse treatment in residential and outpatient settings examines substance abuse treatment under managed care insurance, and compares client characteristics, processes, and outcomes of substance abuse treatment, by gender and ethnicity. At baseline, the women in the study (N = 69), compared to men (N = 91), were on more psychotropic medications, had higher scores for drug dependency, and lower quality of life scores, including symptomatology and functional status. Women also had higher drug use scores before treatment than men, and fewer days of sobriety; after treatment there were no significant differences between women and men. Although these women were more affected by their substance abuse than men at baseline, the differences were eliminated by follow-up.At baseline, Caucasians (N = 103) used more psychotropic medications than Hispanics. Additionally, Caucasians had higher functional status and total quality of life compared to non-Caucasians (Hispanic and African...

Managed Care expansion to Asia: a critical review

The paper examines the concept of Managed Care as practised in Southeast Asia and argues that Managed Care insurers are unlikely to spread further. The first part of the paper reviews individual country experience (Indonesia, Philippines, Malaysia, Hong Kong and Singapore) followed by a summary of difficulties that Managed Care has encountered. Among these are increasing public defiance, opposition by physicians and the already low costs that are unlikely to make Managed Care an attractive option.