Read PDF Understanding Managed Care: An Introduction for Health Care Professionals

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Healthcare's Front Line: Primary Care Physicians Why your family needs a primary care physician and how you can find the right one. You can create a customized Report Card that shows results for the health plan or plans you want to know about. Your Guide to Managed Care Contains section on picking a plan.

What Questions Do I Ask? California Health Scope A resource for making choices about your health care! Administrators in Medicine operate, an organization of state medical board directors, operates a Web site where you can find information on doctors in a growing number of states. The Bloomberg Personal Bookshelf is a series of print products on personal finance that have been converted to 3-hour, two-cassette abridged audiobooks by DH Audio.

Choosing and Using an HMO is an essential guide to a very difficult topic. The author has done a good job organizing her information, writing it and reading the final products. Spragins comes off as an expert. Furthermore, she successfully argues that the consumer needs this information. Anyone starting a family could benefit greatly HMO audiobook. It covers a lot of ground in a well-organized way. The audio is accompanied by a booklet of resources, worksheets and summaries.


Korczyk, Hazel A. Witte, Paperback - pages January , Alpha Books. Health Insurance Basics 2. Health Insurance Needs 3. The Options Checklist 4. Group and Individual Plans 5. Blue Cross and Blue Shield Plans 6. Long-Term Care Insurance 9. Short-Term Plans Federal Employees Health Benefits Program Veterans' Benefits Medicare Medicare Supplement "Medigap" Medicaid Free and Low-Cost Care for the Poor Maximizing Claims By "comparison shopping," you can find the plans that are best for you.

Different comparisons you can make for plans include:. Government Internet site for Medicare consumer information. It is designed to offer a variety of useful and easy to read information about Medicare. Medicare Managed Care - An on-line educational booklet. Patients without access to the Internet can contact a health care provider or a pharmaceutical company to receive information about medication assistance programs. An article from the Hattie Larlham Foundation. Commonwealth Coalition for Community.

Call or visit their Web site. Medicare failure to meet the needs of people with disabilities - especially non-elderly beneficiaries. Includes discussion of Medicare standards for coverage of wheelchairs, scooters and other durable medical equipment. Meeting The Needs of People With Chronic and Disabling Conditions in Medicaid Managed Care xxx fact sheet which discusses "carve-outs" and other methods used to address the health care needs of people with disabilities.

If you have ever sought pre-approval for a necessary medical treatment, or have had problems arranging appointments with a specialist, or have seen a personal-care physician transferred to a distant clinic, George Anders's book on the growth of health maintenance organizations HMOs will confirm your worst fears. A reporter for the Wall Street Journal, Anders provides a series of horrifying case studies: a six-month-old baby who loses his hands and feet after a mile journey to an HMO-approved emergency room; residents of a small town in Tennessee afflicted with an outbreak of a painful bowel infection who find that the drugs needed to suppress the epidemic are not covered; HMOs that select hospitals with low success rates for heart-bypass operations because of cost factors.

Anders presents a powerful indictment of the emerging managed-care model for our national health-care system in this disturbing book. From Booklist , November 1, Anders' analysis of managed care has at its core the supposition that HMOs are the de facto national health care policy of the U. He notes that the "takeover" of health care by HMOs resulted from market forces seeking to contain costs in a bloated health delivery system, and this takeover came about without a single citizen referendum or congressional vote.

This book is for any ordinary person seeking to understand the issues surrounding the explosion of HMO influence and to learn what HMOs do well and where they fail. Anders is forthright in his critique of HMOs.

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He identifies the worst problems in managed care and considers possible solutions. His premise is that people primarily seek health insurance in order to have some medical security in a crisis. The reality of that security is often in doubt as Anders, through numerous interviews, relates stories of experiences that individuals have had with HMOs in times of crisis. A survey of state Medicaid programs found that over two-thirds of responding states with MCOs reported that Medicaid beneficiaries enrolled in MCOs sometimes experience access problems.

Problems with access to dental care, pediatric specialists, psychiatrists and other behavioral health providers, and other specialists e.

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At the same time, improved access to care — both primary and specialty care — was the most frequently cited perceived benefit of managed care relative to fee-for-service. Some states indicated that where an access problem existed, it usually paralleled a similar problem encountered by persons with other types of insurance, for example, due to provider shortages and other market factors.

The survey, however, did not directly collect information on access problems in fee-for-service Medicaid Gifford A secret shopper study conducted by the Office of the Inspector General found that slightly more than half of Medicaid providers could not offer appointments to enrollees. Notably, 35 percent could not be found at the location listed by the plan and another 8 percent were at the location but said that they were not participating in the plan. An additional 8 percent were not accepting new patients. Among the providers who offered appointments, the median wait time was 2 weeks. However, over a quarter had wait times of more than 1 month, and 10 percent had wait times longer than 2 months.

Managed care - Wikipedia

Finally, primary care providers were less likely to offer an appointment than specialists; however, specialists tended to have longer wait times OIG Inadequacies in access to specialist care, stemming from system-wide shortages of specialists and the maldistribution of the specialist workforce, can be worse in Medicaid than among privately insured individuals. Particularly in rural areas, long distances to reach providers and public transportation patterns can create barriers to adequate access; indeed, patients may have to travel 50 to miles to see a specialist.

Access to dental services is often especially challenging, and more so in rural areas. Gaps in access to specialty care may grow even wider if MCOs enroll more beneficiaries with complex needs, who may rely on specialists as their primary care providers or make more use of selected specialized services, such as mental health care Gold and Paradise It is not clear whether managed care provides better or worse access to care than FFS. The same synthesis of research on Medicaid managed care plans shows mixed success in improving access to care.

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There is some evidence of increased likelihood of a usual source of care and reduced emergency department visits Sparer A more recent study found that the transition to Medicaid managed care in Puerto Rico was associated with an increased use of prenatal care services Marin et al. Another study in Mississippi concluded that the number of medications filled, number of office visits, intensity of office visits, total pharmacy costs and total outpatients costs, all of which are indicators of improved access, were found to increase after the shift to managed care.

Days of inpatient stay, inpatient costs and emergency department costs all decreased, which is consistent with the incentives provided under a capitated payment system Ramachandran et al. Conversely, a more recent study of Florida found that Medicaid HMO patients are more likely to be hospitalized for ambulatory care sensitive conditions than were Medicaid FFS enrollees. These results suggest that Medicaid HMO enrollees faced greater barriers to accessing primary and preventive health care services than their FFS counterparts Park and Lee A study of the shift from FFS to managed care in Texas concluded that black-Hispanic mortality, pre-term, and low-birth-weight birth gaps increase by 69, 45, and 12 percent, respectively, after a county switches from FFS to managed care.

Quality of prenatal care generally falls for blacks relative to Hispanics, and black birth rates show a small decline after the switch to managed care. Researchers raised concerns that private, capitated plans have incentives to retain healthy, low-cost patients and shift high-cost clients to competing insurer and, as such, will improve care for the former group relative to the latter Kuziemko et al. Another recent study examined county-level Medicaid managed care penetration and health care outcomes among nonelderly disabled and nondisabled enrollees.

Results for nondisabled adults show that increased Medicaid managed care penetration is associated with increased probability of an emergency department visit, difficulty seeing a specialist, and unmet need for prescription drugs, and is not associated with reduced expenditures. This study found no association between Medicaid managed care penetration and health care outcomes for disabled adults Caswell and Long Findings on Medicaid managed care quality outcomes are scarce and have mixed results. Based on a review of the literature prior to , there is also limited evidence that managed care improves quality of care relative to Medicaid FFS Sparer A more recent study of youths with type 1 diabetes enrolled in Medicaid managed care found that they were less likely to be readmitted within 90 days of discharge that similar patients in FFS, a sign of improved quality Healy-Collier et al.

There are several studies that examine whether enrollment in a managed care delivery system improves the likelihood that a pregnant beneficiary will have a healthy child.

Most such studies prior to find that there is no impact on either birthweight or infant mortality rates. This seems to be true whether the managed care initiative improved access to prenatal care or resulted in reduced access to prenatal care Sparer However, a recent study of the transition from FFS to Medicaid managed care found that black-Hispanic infant health disparities widened among black infants mortality increases by 12 percent while the Hispanic mortality rate decreased by 22 percent Kuziemko et al. There are several reasons why it is difficult to evaluate the effect of managed care on quality of care.

Quality is a somewhat subjective concept and can be evaluated using both process measures e. Health outcomes are produced by a complex combination of factors including various social determinants such as education, housing and culture, making it hard to identify the impact of any particular intervention, including Medicaid managed care. The national average scores on all of these measures are lower for Medicaid managed care enrollees than for individuals in other types of plans.

For example, the rate of high blood pressure control for Medicaid enrollees is lower than the rates for Medicare Advantage enrollees and for individuals with commercial insurance However, important differences between the commercial, Medicare, and Medicaid populations such as health status and income may affect the results. In addition, data are only reported for individuals who are continuously enrolled for 12 months, so they may not be representative of the entire Medicaid managed care population.

Therefore, comparisons among the populations should be viewed with caution. Comparisons among the commercial, Medicare, and Medicaid populations should be viewed with caution because important differences between the populations may affect the results i.

NCQA also publishes data from the CAHPS survey which measures enrollee perceptions of their health plans, providers, overall health, and their ability to access care Table 2. These data show that enrollees in Medicaid managed care plans gave their health plan a higher overall rating compared to privately insured patients but a lower overall rating compared to Medicare patients NCQA They also show that enrollee perceptions of some measures of access and quality are lower for enrollees in Medicaid health plans compared to commercial and Medicare enrollees.

Skip to main content. Managed Care While much research has been conducted on whether managed care delivery systems result in better outcomes than traditional fee for service FFS , there is no definitive conclusion as to whether managed care improves or worsens access to or quality of care for beneficiaries. Aspects of Medicaid managed care that may affect access to and quality of care Economic incentives.

Studies of the relationship between managed care, access, and quality Because managed care networks and organizations can be configured, staffed, and funded in many different ways, it is difficult to make general conclusions about their correlation with better or worse access to and quality of care. TABLE 1. TABLE 2. This measure has two components: effective acute phase treatment for those who remained on an antidepressant medication for at least 84 days and effective continuation phase treatment for those who remained on the medication for at least days.