A survey of human resources in managed care organizations

Although managed health care is increasing exponentially in the United States, minimal published information exists regarding the human resources needed to perform various managed care activities. This article reports on the results of a national survey of managed care organizations regarding the quantitative use of nurse and physician reviewers and the type of activities being performed.     

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.     

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.     

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.     

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.     

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.     

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.     

The future of managed care: the debate continues

The Patient Access to Affordable Care Act has acted as a catalyst in the health care debate over the future of managed care. The Employee Retirement Income Security Act, once a sacred cow, is now under intense scrutiny. Congress is laying the ground work to create consumer protections in health care, but time in this legislative session may run out. If Congress acts this year, there could be a fundamental shift in the control over health care.     

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.     

The managed care world order. The revolution is here

What are the belief clashes caused by the shift from a fee-for-service medical setting to a managed care environment? Right now, most physicians are enculturated in the old world order that emphasizes physician autonomy, control, security, and specialness. Physicians feel squeezed--by third-party payers wanting to be involved in the decision-making process of care delivery and by a new focus on teams versus the captain of the ship role. When traditional expectations clash with a changing reality, most people feel stressed. Physicians are no exception. If physicians have clear and realistic expectations, they can better cope with the uncertainties they face. And, the only realistic expectation in the medical profession is increasing uncertainty. Here are 10 predictions of what is happening in the health care industry--a list of the belief clashes that are so unsettling to those practicing medicine.     

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.     

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.     

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.     

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.     

New directions for an organised health care system in Germany: The concept of managed care

Against the background of continually rising public sector health costs in Germany, Michael Müller and Klaus Uedelhofen discuss the merits of ‘Managed Care’, a philosophy of organised health care, having its origins in the US in the early 1970s. Managed care is based on networking all separate groups within the healthcare system, standardising the services and performance, and distributing or sharing risks between all parties involved. Advantages, beyond cost reductions, include quality assurance, greater transparency, the establishment of therapy standards and increased responsibility by patients. The outlook for managed care in Germany looks optimistic.     

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.     

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.     

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.     

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.