Managed Care Delivery Research Articles

Using performance-based contracts and incentive payments with managed care: Increasing supported employment opportunities for people with developmental disabilities

Managed care delivery systems seem to be one of the primary vehicles that policymakers have selected to control the accelerating costs of public programs, including services to persons with developmental disabilities. The article provides a case example of a Colorado managed care organization that developed a performance-based funding system to improve supported employment services for individuals with developmental disabilities. The presence of achieved outcomes and quality indicators led to additional funding of service agencies. Contractors were given incentives for reaching certain milestones, such as job placement and job stabilization. To strengthen the milestone system, a three-day intensive skill-building training program was developed for the staff of service agencies to become or enhance skills as supported employment consultants. Service agencies with trained staff could bill at a higher rate for their services. Over a period of 3 years, this payment system led to a 37% in the number of long-term job placements in the community.

Two‐year health and employment outcomes among injured workers enrolled in the Washington State Managed Care Pilot Project*†

Increasing numbers of injured workers are being treated through managed care delivery systems, yet little is known about the long-term effects of care provided through these systems. We analyzed health outcomes, return to work, and employment status at 2 years post-injury among a cohort of workers who were previously enrolled in the Washington State Managed Care Pilot Project. Data on functional status, satisfaction with quality of life, return to work and employment status were gathered via telephone interviews and mailed questionnaires from a subset of 374 injured workers who had a time loss claim that involved 4 or more days of lost work time. Of these 374 subjects, 106 were treated through managed care and 268 through fee-for-service (FFS) arrangements. Health outcomes were assessed through the SF-36, the Health Assessment Questionnaire (HAQ), and the Satisfaction with Quality of Life (QOL) instruments. Standard univariate and multivariate statistical methods were used to compare the two groups with respect to the health and employment outcomes. There were no statistically significant differences between the two groups in functional status, satisfaction with quality of life or employment outcomes, except in regard to perceived recovery. FFS patients were more likely to indicate their recovery at 2 years post injury was going well (62 vs. 45%, P = .01). Almost 90% of the injured workers returned to work at some point following their injury and 72% reported working during the 4 weeks prior to their 2-year follow-up interview. Injured workers treated through managed care, based upon an occupational-medicine model, appear to experience similar long-term health and employment outcomes as workers treated through traditional FFS.

Preventive service delivery for children in a managed care environment: contrasts and lessons from Israel

This document describes the Israeli models of preventive health care delivery focusing on the incorporation of preventive health services into a regulated managed care approach. It also addresses the risks and advantages of such changes and provides recommendations on the direction of public health practice in the US and Israel. Preventive services in Israel are provided by the Ministry of Health or its designees through a system of mother and infant neighborhood clinics called Tipat Halav which are similar to public health clinics in the US. In assessing the exportability of programs on preventive health care such programs must be viewed in the context of societal and cultural perspective of the `importing country. In this regard this document demonstrates that the effective Israeli system of Tipat Halav could not likely be imported into the US successfully. Three factors account for this: the existing political imperatives/trends accepted patterns of care delivery and structure of managed care delivery. Hence it is recommended that the US must take deliberate steps to ensure that the changes of responsibility for preventive services must be handled appropriately. Moreover a new payment structure must be instituted to deliver such services to an increasing percentage of their enrollees.

Investigation of Interdisciplinary Learning by Physical Therapist Students During a Community-Based Medical Mission Trip

ABSTRACT. Interdisciplinary medical mission experiences provide opportunities for professionals and students to offer health care to medically underserved communities. The purposes of this study were: (1) to determine the nature of learning among physical therapist students during an interdisciplinary medical mission trip, (2) to determine the perceptions of physical therapist students concerning other disciplines, and (3) to determine the feasibility of developing a communitybased clinical education experience using this type of experience. The subjects were 12 physical therapist students who were in their second or third year of a professional masters degree program and who had not previously participated in a medical mission trip. These students were not enrolled in a class for this experience and did not receive a grade for their participation. Qualitative research methods were used in this study. The design of the study included qualitative data collection prior to, during, and after the experience. Methods of data collection included audiotaped interviews, observations, and videotapes during community-based experiences and the use of student journals. The qualitative data were analyzed through a process of coding, content analysis, and theme development. Reliability was established through independent data analysis by each researcher Validity was established through triangulation of data. Data analysis resulted in the development of four themes: (1) adaptation to the environment, (2) collaboration with peers and team members, (3) development of cultural sensitivity, and (4) development of a holistic approach to patient care. Adaptation to the environment had several subthemes, including creativity, prioritization, problem solving, education, and communication. The results of this study indicate that through social cognitive learning, students develop higher-level thinking and problem-solving skills in addition to cultural sensitivity and collegiality with other health care providers. These types of experiences are an important part of professional development and should enhance the students' abilities to function in today's changing health care environment. Therefore, communitybased clinical experiences are viable options to supplement the decrease in traditional clinical education experiences. The delivery of health care continues to evolve in a manner that necessitates changes both in academic and clinical curricula of health care professions.1,2 The focus of a managed care delivery system, in which care is streamlined and in-patient hospital stay is shortened, heightens the need for an interdisciplinary approach to patient care. Although physical therapist (PT) students encounter other health care professionals during clinical experiences, the interaction may be limited and structured to the extent that a full understanding of other disciplines is not appreciated. Traditionally, students who are assigned to a rehabilitation clinical experience participate in an interdisciplinary approach to patient care. However, the changes in health care now necessitate an interdisciplinary approach throughout the continuum of care.3 Thus, it is important for students to experience and understand the roles of other health care team members early in their professional education. Health care professions programs must seek innovative activities through didactic course work as well as clinical education experiences to ensure that students are acquiring competencies that facilitate adaptation to the changing health care environment. Out of necessity, clinical education is changing.4 Alternative models of clinical education are needed to accommodate the changes in health care delivery. Some of these alternative models include varying ratios between students and clinical instructors (CIs) and placement of students in nontraditional settings. Student ratios may include two CIs to one student, one CI with two or more students, or multiple CIs with multiple students. …

Managed care litigation: legal doctrine at the boundary of tort and contract.

This article summarizes the various approaches to how the law should assign responsibility in a system where health care financing and delivery are combined. Health law scholars have been debating whether conflicts in managed care between individual patient needs and preserving assets for the patient population should be resolved by tort or contract law. Until recently, the literature has been dominated by scholars arguing that managed care should be guided by contractual arrangements and concepts to stimulate the market changes occurring in health care delivery. We summarize the arguments for and against both contract and tort, along with recent attempts to bridge the gap between the two approaches. The case in favor of a contract regime fails to account for the hybrid nature of managed care delivery and the context in which managed care litigation arises. Thus, tort law retains a fundamental monitoring role in the managed care era.

Integrated risk assessment and feedback reporting for clinical decision making in a Medicare Risk plan.

The challenge of tapping into the rich resource of population-based, aggregated data to inform and guide clinical processes remains one of the largely unrealized potentials of managed care. This article describes a multifaceted approach of using health-related data to support providers in clinical decision making as an adjunct to case management and primary care delivery. The goal is to provide data that can be used for clinical decision making that is population based, yet individualized for specific patient care situations. Information reporting holds great potential in the clinical care of patients because it can be used to identify persons who could benefit from early detection, intervention, or treatment. It has been suggested that one of the keys to success in managed Medicare is the timely use of information that is detailed, comprehensive, and real-time describing key parameters of clinical encounters.

Ethics of case management: implications for advanced practice nursing.

The healthcare system is under pressure to provide quality care with less money for a growing and aging populace, and the resulting changes in the system could pose ethical problems for advanced practice nurses. Expanding healthcare needs, the increased use of technology, and dwindling resources all place burdens on advanced practice nurses, who have taken on the role of case manager in an attempt to reduce costs, meet patient outcomes, and provide improved, personalized, high-quality care. This paper explores the ethical concerns that can arise from managed care delivery systems and discusses the role of advanced practice nurses as case managers and the possible implications for nursing practice and research.

"Patient" versus "Client"

Back to table of contents Previous article Next article LetterFull Access"Patient" versus "Client"Verinder Sharma, M.B., B.S., F.R.C.P.(C.), Diane Whitney, M.D., F.R.C.P.(C.), Shahé S. Kazarian, Ph.D., C.Psych., and Rahul Manchanda, M.D., F.R.C.P.(C.)Verinder SharmaSearch for more papers by this author, M.B., B.S., F.R.C.P.(C.), Diane WhitneySearch for more papers by this author, M.D., F.R.C.P.(C.), Shahé S. KazarianSearch for more papers by this author, Ph.D., C.Psych., and Rahul ManchandaSearch for more papers by this author, M.D., F.R.C.P.(C.)Published Online:1 May 2000https://doi.org/10.1176/appi.ps.51.5.677-bAboutSectionsView EPUB ToolsAdd to favoritesDownload CitationsTrack Citations ShareShare onFacebookTwitterLinked InEmail In Reply: We agree with Mr. Kensinger's view about the contextual nature of the use of terminology. In our study, we did not examine specifically the preferences of service providers and service recipients for the term "customer." However, the term was not suggested by any of the service providers in our "other" category, nor was it endorsed appreciably by service recipients. Interestingly, according to Collins English Dictionary (1), one of the meanings of "client" is "customer."As we discussed in our article, the difference in the use of terms in Canada and the United States may be in part related to universal versus managed care delivery systems. The choice of term is perhaps a matter of personal preference and not the literal meaning from the dictionary.We thank Dr. Cahn for his comments. To the best of our knowledge, there are no systematic data to support the increased trend in use of the term "client" over "patient." Although the literal meaning of the terms may differ, the choice of the word really refers to the connotation inferred by the individual. As noted above, one meaning of the word "client" is "customer," a term in vogue but not preferred by our study population. We doubt if our colleagues and patients actually looked in a dictionary to decide on their preference for describing a service recipient.

Medicaid managed care and children with special health care needs: A case study analysis of demonstration waivers in three states

Although the number of states moving toward managed care for Medicaid beneficiaries is increasing, little is known about the extent to which managed care delivery systems are prepared to address the special needs of children with chronic illness and disabilities. This study explores the change in the process of care provided by the State Title V Programs for Children With Special Health Care Needs (CSHCN) and in parent and provider satisfaction when Medicaid changes the method of payment from fee-for-service to capitation. The findings suggest that CSHCN are vulnerable in a managed care environment and that states should proceed cautiously to integrate this population into their managed care arrangements.

Perspectives of health workers regarding primary health care delivery to the rural population in the Bothaville district.

This article reports on the views of public health workers regarding recent changes in the delivery of primary health care to people living and working in the Bothaville rural area. These changes in mobile health care form part of the Initiative for Sub-District Support's programme to provide sustained, concerted support to sub-districts to bring about improvements in health care management and health care delivery. Main shortcomings of the recent changes were identified as inadequate transportation facilities in rural areas, insufficient information dissemination to rural dwellers and lack of farmers' participation in rural health matters. Furthermore, poor communication and co-operation between different public health services prevailed and the need for an integration of these services was emphasised.

Psychiatric provider practice management companies: adding value to behavioral health care?

tients or organizing to form managed care delivery systems. The latter choice involves consolidation and development of the capability to manage risk contracts, allowing clinicians to reclaim clinical control. To meet this challenge, a new class of behavioral health care organizations has emerged: the psychiatric provider practice management company. Like the physician practice management companies on which they are modeled, psychiatric provider practice management companies are adopting a wide range of strategies to allow behavioral health clinicians to control a larger share of the premium dollar. To understand psychiatric provider

Nothing exceeds like success: managed care comes to Medicaid in New York City.

Nearly every state is encouraging or requiring Medicaid beneficiaries to enroll in managed care delivery systems. In New York City, Medicaid officials began with an incremental, but not insignificant, managed care initiative. Buoyed by its success, New York policy makers tried, and failed, to accelerate the transition to managed care. The legacy of that failure still plagues them. A comparison of such initiatives in other states indicates that most state officials have remembered what New York's leaders temporarily forgot, namely, that Medicaid managed care is a complex exercise that demands consultation and consensus building.

Are you ready for ssmos?

Abstract While welfare reform altered entitlements, introduced time-limited benefits, and capped reimbursements for administrative costs, little was done to control service utilization by those who remain on welfare, or to realign the financial incentives and administrative infrastructure for the delivery of social services. This essay explores the advent of the Social Service Maintenance Organization and discusses the steps that social service agencies need to take to ready themselves for this altered system of service delivery. Without a thorough understanding of the way in which managed care delivery systems operate, as well as the sophisticated information systems and the financial resources necessary to assume risk, social service agencies will find themselves increasingly ill-equipped to meet the challenges of this new environment.

Managed care and the prevention of unintended pregnancy.

Managed care organizations (MCOs) hold the potential to help address the significant public health issue of unintended pregnancy. Managed care's delivery of women's primary care and family planning services is reviewed. Some MCOs provide better coverage of contraceptive options as well as better confidentiality protections, but not enough is being done in partnering with existing family planning providers and in educating providers about the need to provide family planning counseling, particularly for adolescents. Performance indicators should be developed to create incentives for health plans to assess their success in reducing unintended pregnancy within their enrolled populations.

NorthMed HMO.

SummaryNorthMed HMO is viewed by its owners as an important vehicle for integrating rural providers in northern Michigan. Through the HMO, rural providers hope to be able to contract with government programs, while retaining private‐sector patients through employer contracts.For most rural providers, NorthMed HMO does not yet represent a major source of revenues. However, the HMO is about to embark on an expansion that, if successful, will increase its importance to providers and its visibility within the service area. This planned expansion is likely to place severe demands on the financial and managerial resources of the organization.Physicians. NorthMed HMO offers a model of a rural‐based HMO in which physicians play a dominant role. Rural physicians in northern Michigan own Northern Physician Organization, a physician organization which, in turn, is the major stockholder in NorthMed HMO. The geographic expansion of the HMO is tied, in large part, to the geographic expansion of the membership of Northern Physician Organization. NorthMed HMO enters new communities when a significant number of physicians in those communities joins Northern Physician Organization. When physicians purchase ownership shares in the physician organization, they indirectly become part owners of the HMO.Participation in NorthMed HMOs network has offered limited benefits to rural physicians at a minimal cost. By being a participating provider in NorthMed HMO, physicians can remain available to their patients who choose the HMO as a health insurance option. NorthMed HMO has not been aggressive in attempts to influence physician practices, and physicians bear no financial risk as a result of their participation. Participating physicians are paid under a fee‐for‐service arrangement with no risk sharing related to hospital use. Indirectly, through Northern Physician Organization's ownership role in the HMO, physicians have the potential to gain financially from NorthMed HMOs growth if the HMO were to be sold, but this diffuse incentive is unlikely to have an impact on physicians' day‐to‐day behavior.The relationship between NorthMed HMO and its physicians is likely to change soon. The number of HMO patients seen by physicians will increase if the HMO succeeds in securing Medicare and Medicaid contracts, and if its new point‐of‐service option attracts additional private‐sector enrollees. NorthMed HMO plans to contract with Northern PhysicianOrganization on a capitated basis to serve the HMOs enrollees, an arrangement that would place financial responsibility for managing care delivery more directly on participating physicians. This is likely to result in more aggressive utilization review and quality assurance measures. In effect, rural physicians will be faced with a difficult trade‐off that they have, to this point, largely avoided: They will be asked to accept financial risk and oversight of their practices in return for the assurance that their HMO can successfully compete for local patients (and their insurance dollars) against health plans that are owned and managed by entities located outside of their rural area.

Collaborative approaches to purchasing and managing oncology services for a prepaid population.

Change created by managed care plans is producing tensions among oncology care providers, health plans, patients, and employers. Managed care plans, which now are dominant, are engendering concern among some patients and providers because those plans limit provider choice and reimbursement, as well as inject themselves in clinical decision-making. Collaborative approaches to purchasing and managing oncology service for a prepaid population should help reduce these tensions. This article provides a case history of how Harvard University Health Services, a managed care delivery and insurance program serving the university collaborates with contracted oncology providers. The described approach defines mutually beneficial payment and shared responsibility for care in the context of patient centered values. As a part of this collaborative effort, liberal experimental treatment coverage is offered. Patient care is improved because the flow of clinical information among caregivers is improved. When communication is more open, nurse case managers who work for the managed care plan also can arrange for covered services in a more expeditious manner. Collaboration among health plans, oncologists, and other health care providers to provide patients with high quality, cost-effective care on a fully informed basis is challenging, but not impossible. The key is to define common ground and commitment to the needs of patients among health plans and providers.

Prevention of Sexually Transmitted Diseases in an Era of Managed Care: The Relevance for Women

New directions in public health will inevitably result from the intersection of three high priority, yet overlapping, issues: 1) the increasing concerns for women’s health; 2) the perpetual challenges of sexually transmitted diseases (STDs); and 3) the emerging opportunities from managed care. With the explosion of various managed care delivery systems, policy makers need to consider how to use these organizations to improve health outcomes for women at risk for STDs.1 Although managed care is not a monolithic system, certain features of managed care organizations (MCOs) may lead to a greater capacity to prevent, screen, diagnose, and treat STDs in women.2 The challenge is what to preserve from the ‘‘old’’ mix of public clinics and private fee-for-service practices and what to emphasize within a ‘‘new’’ MCO system to produce a maximum impact on reducing sexually transmitted infections in women, their partners, and offspring. In this article, we first describe the unique association of women with STDs. We then explain the basic elements of our current public health system to prevent and treat STDs. Next, we address the possible ways that managed care can affect our current system. Finally, we conclude with recommendations for how to marshall the resources afforded by managed care to minimize STDs in women.

Medicaid Managed Care and Childhood Immunization Delivery

Childhood immunization rates can be used as a barometer of the quality of care delivered to children. Medicaid managed care has the potential to improve childhood immunization delivery by implementing population-based medicine in primary care. Studies of immunization rates under Medicaid managed care have found mixed results; in some settings immunization rates were higher for children covered by Medicaid managed care than for children covered by fee-for-service Medicaid, but in other settings immunization rates were similar for children in the two types of Medicaid programs. In most studies, overall rates were well below national guidelines for all populations enrolled in Medicaid.

Legal Protections to Ensure Linguistically Appropriate Health Care

Nearly 32 million people in the United States, 13.8 percent of the population, speak a language other than English at home, and our health care delivery system is hard-pressed to handle this diversity. Most pressing is the need for adequate translation services. Many U.S. hospitals rely on untrained employees or advise patients to bring friends or family members with them to translate. Thus, interpreter and translation needs often go unmet or are handled inappropriately. A number of federal and state laws impose legal obligations on health care providers to offer at least minimally adequate translation services for limited English-proficient patients. This article outlines the scope of these legal requirements and discusses the need to ensure linguistically appropriate care in the emerging managed care delivery system.

The dissemination of manual-based psychotherapies in managed care: Promises, problems, and prospects.

Manual-based, empirically validated psychotherapies potentially have a very important role to play in building quality managed care delivery systems. Unfortunately, managed care systems have been slow to endorse or implement such models of care on a widespread basis. The essence of the problem is that manual-based procedures have been developed primarily to address the needs of clinical science and little attention has been directed toward the three primary end users in applied settings: the behavioral health program director, the line clinician, and the consumer of behavioral health services. The result is that manual-based therapies are perceived as highly specialized, cumbersome, time consuming, expensive, difficult to train/supervise, and not user friendly to either line clinicians or consumers. Here, the perspectives of the clinical scientist, practitioner, behavioral health program director, and consumer are reviewed to highlight how manual-based procedures could be tailored to fit the demands of all key stakeholders. If these changes are made thoughtfully, manual-based procedures may eventually become a dominant mode of service delivery in managed care.