The use of imperfect data in managed care organizations

Two critical milestones appear to be occurring in the development of medical groups moving to improve medical care effectiveness. These include the abilities to work with imperfect and unflattering data. There is a clear linkage between these two concepts, because forward clinical improvement or business planning is often delayed as individual physicians seek to await "perfect data" when confronted with unflattering information. In the form of "profiles" in particular, providers often react negatively, with complaints that the information is "imperfect" or that it fails to capture some nuance of their sicker or unique patient populations. The translation of imperfect information to effective clinical practice anyway remains a success fundamental to managing highly competitive medical groups and health plans. It is centrally dependent on the understanding, use, and application of "imperfect data".     

Trends in managed care organizations: implications for the physician executive.

The rapid change in the managed health care industry is placing substantial demands on the managerial and leadership skills of physician executives. These changes are forcing a reevaluation of the fundamental principles of managed care organizations, specifically in terms of patient satisfaction, cost containment, and quality health care. Additionally, the physician executive will be confronted with substantial issues concerning future staffing needs. This article assesses the health care industry's environment to suggest where managed care is going and how physician executives should position themselves to optimize their position in the marketplace.     

Credentialing in managed care

Through the use of managed care techniques in recent years, the insurance industry has tried to bring the runaway costs of medical care under control. The result of this control effort is system access limitations, compared to the full choice indemnity plans of the past. This limited system access has now clearly moved HMOs and other managed care organizations into the category of "potentially liable health care entities," based on patient steerage, economic disincentives, and limited choices of the plan's participating providers and facilities. Just as hospitals have had to exercise rigorous care in the credentialing of members of their medical staffs, managed care organizations will have to ensure that the providers they use meet acceptable standards of competence.     

A guide to evaluating managed care companies

Managed care has gradually been replacing the traditional way in which doctors and patients interact. These changes are taking place at an increasing pace, which strongly suggests there will be a dramatic trend to managed care programs. It has become imperative to understand the business of medicine beyond the traditional "business manager" tasks of setting fees, analyzing tax consequences, and balancing the check book. Providers may be hard pressed to maintain the quality of care they feel comfortable giving as the regulations of managed care exert their pressures. A rational, systematic approach to evaluate managed care firms is presented in this article. Additional criteria will have to be added as new ideas for managed care evolve. Physicians and practices must make decisions concerning the level of their participation, depending on a variety of factors, some more sensible than others.     

A framework for production control in health care organizations

The paper presents a hierarchical framework for production control of hospitals which deals with the balance between service and efficiency, at all levels of planning and control. The framework is based on an analysis of the design requirements for hospital production control systems. These design requirements are translated into the control functions at different levels of planning required for hospital production control. The framework consists of five levels of planning and control: patient planning and control, patient group planning and control, resources planning and control, patient volumes planning and control and strategic planning, though this last level does not make part of production control as such. Each of the levels of the framework is further elaborated in terms of the decisions made regarding patient flows and resources, and the co-ordination of the different planning levels. Implications of the framework are discussed by describing some points where current practice deviates from assumptions made in our approach. Recommendations for future research and development of the planning framework are formulated.     

Important points in managed care contracts

Health care is increasingly managed through some contractual relationship. Such contracts vary and the contracting entities may be clinics, universities, health maintenance organizations, individual practitioner organizations, preferred provider organizations, corporate health plans, or other structures. It is estimated that within 10 years more than 70 percent of all health care will be provided through some type of managed care plan.     

Seeing systems in health care organizations

"Systems" in health care organizations are difficult to visualize and understand by people across the organization. Systems exist as behaviors that have reasons and consequences rather than strict, linear cause and effect relationships. Learn how to sketch and see the systems at work in health care, and how to change them to help end the blame game.     

Legal implications of managed care arrangements

Prior to the 1980s, managed care was virtually nonexistent as a force in health care. Presently, 64 percent of employees in America are covered by managed care plans, including health maintenance organizations (20 percent) and preferred provider organizations (44 percent). In contrast, only 29 percent of employees were enrolled in managed care plans in 1988 and only 47 percent in 1991. To date, the primary reason for this incredible growth in managed care has been economic-market pressure to reduce health care costs. For the foreseeable future, political pressures are likely to fuel this growth, as managed care is at the center of President Clinton's national health care plan. Although there are numerous legal issues surrounding managed care, this article focuses primarily on antitrust implications when forming managed care entities. In addition, the corporate practice of medicine doctrine, certain tax issues, and the fraud and abuse laws are discussed.     

Paying physicians in advanced managed care markets

Physician compensation in managed care environments has undergone dramatic change over the last five to 10 years. Early goals that originally involved reduction in unit price have been replaced by a variety of variable pay formulas for primary care physicians and specialists alike. Criteria for determining provider variable pay include demonstrable member access, patient satisfaction, and economic performance. Based on emerging trends, physician payment should be modified to include measurements based on productivity and quality of life.     

Keeping the "care" in managed care: the importance of the therapeutic relationship and psychosocial factors in the managed care setting

There is much truth in the adage that "the more things change, the more they stay the same." Nowhere does this seem more apparent than in health care where, amidst monumental reconfiguration, basic foundations of physician-patient relationships and attention to the impact of psychosocial factors on health and health care delivery remain as critical influences. While the importance of the therapeutic relationship and the influence of psychosocial factors in medical care has been clear in traditional systems of delivery, these factors may be even more critical in managed care systems. These emphases must be incorporated by design, however, and not left to default.     

The health of health care organizations

Abstract

This paper explores the nature and development of health care organizations in terms of a model of organizational healthiness. The model places particular emphasis on the psychosocial subsystems which describe the subjective organization. These represent the perceived internal functioning of the organization in terms of task completion, problem solving and staff development. The implications of such a model for the well-being of health care staff and for the evaluation of service delivery are discussed.     

Ethics in the management of health care organizations

This article introduces the topic of ethics in the management of health care institutions and provides a glimpse at how issues of ethics have grown in recent years and are apt to be applied in the future. Ethics and some of its basic conceptual and practical tools are defined. A brief history of the ethics of managing health care institutions, a crucial context for understanding the contemporary ethics of health care institutions, is provided. What has changed in the past 10 years and how those changes have resulted in the ethical heterogeneity of contemporary health care institutions is discussed. Finally, some preventive ethics strategies for the management of health care institutions are suggested.     

The appointment-keeping habits of managed care patients

Among the controversies surrounding the provision of health care in a managed care environment is the belief that patients, because they have no particular allegiance to a single physician, are more casual in regard to their keeping appointments. To test this proposition, the authors conducted a study at a California independent practice association, comparing the habits of managed care patients with those of other types of patients. The findings, although based on a limited sample, suggest that managed care patients do indeed have a greater tendency to be appointment no-shows.     

Practicing managed care in the academic medical center

The purpose of this article is to outline the contrasts between the traditional AMC and an organization oriented toward the delivery of population-based managed care. Academic medical centers differ from one another considerably in the extent to which they serve as quaternary care community resources, the degree to which they emphasize primary care in training and care delivery, and the amount of research undertaken. Nor is there a single organizational structure for managed care; successful managed care is practices in IPAs, multispecialty groups, PHOs, and staff-model HMOs. Nonetheless, the contrasts outlined here between AMCs and managed care organizations (MCOs) are valid in most cases.     

Success in managed care: improving clinical quality

What are the economic elements for success in managed care? Although they are quite simple, achieving them can be difficult. The criteria for success in the fee-for-service medical delivery system, generally characterized as "see more--do more--get more," are no longer valid for delivering care in a managed care system. This article identifies the economic elements for success in managed care, and offers a disciplined approach to achieving them, combining both actuarial and clinical expertise.     

Legal developments in managed mental health care.

There has been rapid development in recent years of employer programs aimed at controlling the skyrocketing costs of providing mental health care benefits to employees. This column, which is based on a presentation at a Client Briefing Conference conducted by Epstein Becker & Green, P.C., on September 13, 1989, in Dallas, Tex., discusses some of the legal issues that have arisen in connection with the various plans that have been developed.     

Does managed care need to be replaced? "Father" of managed care unveils new plan.

In a recent speech at the Graduate School of Management, University of California, Irvine, managed care architect Paul M. Ellwood, Jr., MD, outlined an ambitious vision for a dramatic new business model and clinical plan for health care of the future. Here's the complete text of his landmark speech, along with an update on where the plan stands today.     

The next stage of managed care.

Since the turn of the century, we have gone from medicine as a cottage industry, based largely on barter, to the complex entity it is today. What we will see in the coming decade, if not sooner is the emergence of the next level of managed care. As managed care matures, contradictions in the health care system that we have not been able to resolve will be addressed, as well as other value-related issues. The ability to deliver value and then to monitor outcomes will be the nut to crack. The next big movement will be to hone in on outcomes and measurement. This will be the path to increasing the inherent value of the medical care system. This will go hana in hand with accountability, which is where physician-sponsored networks (PSNs) will be an indispensable tool. Centered as they are around accountability and responsibility, PSNs will be a natural starting point for developing the protocols to produce and collect this data. The standardization of care, anchored upon medical evidence, is the objective.     

An overview of managed care in state Medicaid programs

The National Governor's Association predicts that Medicaid will account for 28 percent of total state spending in 1995, double the 1991 level. During 1992, total Medicaid enrollment reached 31.6 million beneficiaries, up 4.7 million (17.5 percent) from 1991. The total expenditure of $118.2 billion in 1992 was up 25 percent from the 1991 level of 94.5 billion. A recent General Accounting Office (GAO) report, revealed that, in 1990, 43 percent of 99 million emergency department visits were for minor ailments. From 1985 to 1990, Medicaid emergency department visits increased 34 percent, compared to 19 percent growth in all emergency department visits. A Department of Health and Human Services Inspector General Report on Medicaid recipient emergency department usage recommended that states develop a comprehensive initiative to reduce nonemergency usage of the emergency department, including increased implementation of managed care options. During 1992, 42 states used some type of Medicaid cost containment measure, with managed care being the most frequent choice.