Managed Care Organization Patients Research Articles

EMS and Managed Care: The Los Angeles Experience

Background. Patients belonging to a managed care organization (MCO) who call 9-1-1 are typically transported to their MCO facility only if it is also the closest emergency department (ED). As past medical records and close follow-up are unavailable at the non-MCO facility, unnecessary workups and/or admissions may result. Objective. To examine the safety and feasibility of preferentially transporting MCO patients to the closest MCO ED rather than the closest ED. Methods. This was a retrospective review over a 52-month period comparing all patients transported by ambulance to an MCO ED when that destination was not the closest ED (targeted group) with all other transported patients. If the MCO facility was not the closest ED, then the emergency medical services (EMS) provider would be reimbursed an additional fee beyond the routine ambulance charges. The primary outcome measure was the additional ambulance transport time. The secondary outcome measure was mortality within the first 24 hours. Results. There were 15,938 patients transported under this program from July 2000 through December 2004 for whom outcome data were available. Of these, 10,532 (66%%) were transported by advanced life support (ALS) ambulance. The mean (± standard deviation) transport time to the hospital for all targeted patients transported during the study interval was 10.4 minutes (±3.2 minutes) compared with 8.6 minutes (±2.1 minutes) for all transported patients (p < 0.001). No patient required ventilatory support in the field. Twelve (0.1%%) patients died during the subsequent hospital admission and, after a blinded chart review, none of the deaths were deemed to be preventable or likely to have resulted from additional transport time. Conclusion. Our study suggests that paramedic transport of MCO patients to the nearest MCO hospital in lieu of the nearest ED is safe and feasible. Given the potential benefits to patient care, this program should be evaluated in other EMS systems.

Blood pressure goal attainment according to JNC 7 guidelines and utilization of antihypertensive drug therapy in MCO patients with type 1 or type 2 diabetes.

Controlling hypertension (HTN) in patients with diabetes mellitus (DM) can reduce complications such as nephropathy, cerebrovascular disease, and cardiovascular disease. As part of a quality improvement project with a managed care organization (MCO), we evaluated blood pressure (BP) control relative to the type of drug therapy for patients with type 1 or type 2 DM who were identified from pharmacy claims for antihyperglycemic drug therapy. Pharmacy claims for antihyperglycemic drugs, including insulin, were used to identify a random sample of commercial members in an MCO comprising 30 health plans across the United States. Retrospective medical record review was conducted in October 2003 to collect data from 4,814 patient charts. BP goal attainment according to The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC 7) guidelines was determined for each patient from the most recent BP reading documented in the medical chart. The distribution by type of DM was 21.0% (n = 1,011) for type 1, 75.7% (n = 3,644) for type 2, and 3.3% (n = 159) for cases not documented in the medical chart. Excluding 590 charts (12.3%) without BP values, there were 1,328 of 4,224 DM patients (31.4%) at JNC 7 BP goal (< 130/80 mm Hg). Of the 1,328 patients at JNC 7 BP goal, 577 (43.4%) were at JNC 7 BP goal with no drug therapy. Excluding the 577 patients who did not require drug therapy to reach JNC 7 goal, 751 (20.6%) of the remaining 3,647 patients who required antihypertensive drug therapy were at JNC 7 BP goal, and 788 (21.6%) received no antihypertensive drug therapy. For the population of 4,224 DM patients with a BP value recorded in the chart, application of the lower BP goals in the JNC 7 guidelines reduced the proportion with controlled BP to 31.4% (1,328/4,224) from 42.6% (1,799/4,224) according to the former JNC 6 guidelines (P < 0.01). The proportion of DM patients with HTN was 59.6% (n = 2,870), and 28.4% (n = 814) of these patients were not taking either an angiotensin-converting enzyme inhibitor (ACEI) or an angiotensin receptor blocker (ARB). There were 704 patients with albuminuria or nephropathy (14.6%), of which 35.4% (n = 249) were not taking either an ACEI or an ARB, preferred therapy in these patients. In this population of MCO members with DM for whom a BP value was recorded in the medical chart, 13.7% met JNC 7 BP goal with no antihypertensive drug therapy. For the patients with DM who received antihypertensive drug therapy and had a BP value recorded in the medical chart, only 26.3% were at JNC 7 BP goal. The application of JNC 7 guidelines significantly reduced the proportion of DM patients at target BP goal from 42.6%% to 31.4%

Managed care organization authorization denials: Lack of patient knowledge and timely alternative ambulatory care

Study objective: To assess patient knowledge of managed care organization (MCO) regulations, availability of alternative ambulatory care, and patient outcome after MCO insurance authorization denial for an emergency department visit. Methods: A medical screening examination and a follow-up structured interview were conducted with patients denied authorization for ED visits. The study was conducted at a large urban hospital with 36,000 annual ED visits and 40% MCO patients. Results: During a 7-month period, 151 patients did not receive MCO authorization for ED care. The interview response rate was 75% (104/138) with 13 patients excluded. Eighty-three percent (86/104) of respondents came to the ED because they believed their problem was an emergency. Four percent (4/104) of the respondents had been instructed to go to the ED but were later denied authorization, whereas 85.6% (89/104) did not know that the MCO could deny payment. Only 37% (38/104) of the respondents reported having received instruction on the MCO preauthorization process, whereas of the 19% who contacted their MCO as instructed, all resulted in scheduling difficulties. Although 57% (59/104) received follow-up within 24 hours, 11% (11/104) of the respondents had a subsequent return visit to the ED with a subsequent admission rate of 4% (4/104). Conclusion: Few patients are aware of the need for MCO preauthorization for ED care, and almost half do not receive alternative care within 24 hours. A significant number of patients (11%) returned to the ED with an admission rate of 4%. [Viner KM, Bellino M, Kirsch TD, Kivela P, Silva JC. Managed care organization authorization denials: lack of patient knowledge and timely alternative ambulatory care. Ann Emerg Med. March 2000;35:272-276.]

Validation of self-report of influenza and pneumococcal vaccination status in elderly outpatients

Objective: To assess the validity of self-reported influenza and pneumococcal vaccination status. Design: Cross-sectional surveys of outpatients aged 65 years or older. Setting: A Veterans Affairs Medical Center (VA) and a community managed care organization (MCO). Both organizations have organized influenza and pneumococcal vaccination programs. Subjects: VA subjects included all elderly respondents to a mailed survey of 500 randomly selected outpatients. MCO subjects included all respondents to a telephone survey of 300 randomly selected elderly members of the MCO. Measurements: The VA survey was conducted following the 1995–1996 influenza season while the MCO survey was conducted following the 1994–1995 season. Self-report from the mailed survey for VA subjects and from the telephone survey for MCO subjects was compared to medical record documentation (paper and computerized combined). Results: The response rate was 77% ( n = 369) for the VA subjects of whom 195 (53%) were aged 65 or older. The response rate for the MCO subjects was 84% ( n = 237). Self-report of influenza vaccination had a sensitivity (SENS) of 1.0 and a specificity (SPEC) of .79 with a kappa of .72 (95% CI .58–.86) among VA patients. Among MCO patients, self-report of influenza vaccination had a SENS of .98 and a SPEC of .71 with kappa of .75 (95%CI .69–.89). Self-report of pneumococcal vaccination status among VA patients had a SENS of .97 and a SPEC of .53 with a kappa of .42 (95%CI .32–.52). Among MCO patients, self-report of pneumococcal vaccination had a SENS of .90 and a SPEC of .64 with a kappa of .54 (95%CI .40–.68). A secondary analysis excluding subjects living outside of the VA’s catchment area improved the specificity and indices of concordance of self-report of both influenza and pneumococcal vaccination. A secondary analysis of MCO data which excluded subjects who received a pneumococcal vaccination > 2 years prior to the study also improved concordance and the negative predictive value of self-report. Conclusions: Self-report of influenza vaccination is a highly sensitive and moderately specific measure. Self-report of pneumococcal vaccination is also a highly sensitive but less specific measure of vaccination status. Lower rates of validity for pneumococcal vaccination may reflect both less accurate recall, particularly for more distant vaccination, and less complete documentation in medical records.

Use of services by diabetes patients in managed care organizations. Development of a diabetes surveillance system. CDC Diabetes in Managed Care Work Group.

To develop a diabetes surveillance system that estimates the prevalence of diabetes and characterizes service use in diverse managed care organizations (MCOs). Computerized inpatient, pharmacy, outpatient, and laboratory records were used to develop an algorithm to identify diabetes patients and to develop surveillance indicators common to the three participating MCOs. Using 1993 data, the availability, specifications, and limitations of various surveillance indicators were determined. An extensive set of diabetes surveillance indicators was identified from the four sources of data. Consistent data specifications across MCOs needed to consider variation in the type of data collected, a lack of documentation on level of coverage, differences in coding data, and different models of health care delivery. A total of 16,363 diabetes patients were identified. The age-adjusted prevalence of diabetes ranged from 24 to 29 per 1,000 enrollees. Approximately one-third of patients with diabetes (32-34%) were taking insulin. The majority had one or more visits to a primary care physician during the year (72-94%). Visits to specialists were less frequent. Ophthalmologists and optometrists were the most commonly used specialists: 29-60% of the patients with diabetes at the three MCOs had visited an ophthalmologist or optometrist. About one-fifth had an overnight hospital stay during the year. This diabetes surveillance system is a useful tool for MCOs to track trends in prevalence of diabetes, use of health services, and delivery of preventive care to individuals with diabetes. This system may also be useful for health care planning and for assessing use changes after new developments in diabetes care or new quality management initiatives.