Managed Care Organization (managed + care_organization)

Distribution by Scientific Domains


Selected Abstracts


Alcohol Drinking Patterns and Health Care Utilization in a Managed Care Organization

HEALTH SERVICES RESEARCH, Issue 3 2004
Gary A. Zarkin
Objective. To estimate the relationship between current drinking patterns and health care utilization over the previous two years in a managed care organization (MCO) among individuals who were screened for their alcohol use. Study Design. Three primary care clinics at a large western MCO administered a short health and lifestyle questionnaire to all adult patients on their first visit to the clinic from March 1998 through December 1998. Patients who exceeded the National Institute on Alcohol Abuse and Alcoholism (NIAAA) guidelines for moderate drinking were given a more comprehensive alcohol screening using a modified version of the Alcohol Use Disorders Identification Test (AUDIT). Health care encounter data for two years preceding the screening visit were linked to the remaining individuals who responded to one or both instruments. Using both quantity,frequency and AUDIT-based drinking pattern variables, we estimated negative binomial models of the relationship between drinking patterns and days of health care use, controlling for demographic characteristics and other variables. Principal Findings. For both the quantity,frequency and AUDIT-based drinking pattern variables, current alcohol use is generally associated with less health care utilization relative to abstainers. This relationship holds even for heavier drinkers, although the differences are not always statistically significant. With some exceptions, the overall trend is that more extensive drinking patterns are associated with lower health care use. Conclusions. Based on our sample, we find little evidence that alcohol use is associated with increased health care utilization. On the contrary, we find that alcohol use is generally associated with decreased health care utilization regardless of drinking pattern. [source]


Ambulatory Use of Ticlopidine and Clopidogrel in Association with Percutaneous Coronary Revascularization Procedures in a National Managed Care Organization

JOURNAL OF INTERVENTIONAL CARDIOLOGY, Issue 3 2002
DEBORAH SHATIN PH.D.
The aim of this study was to quantify ambulatory use of ticlopidine and clopidogrel in association -with percutaneous coronary revascularization procedures (PTCA, atherectomy, stent) in a national managed care organization. Retrospective administrative claims data over a 3-year period (1996,1998) from 12 UnitedHealth Group-affiliated health plans in four geographic regions were collected. Pharmacy and medical claims data were used to determine the patients exposed to ticlopidine and clopidogrel between January 1, 1996 and December 31, 1998, the duration of use, prescriptions within 2 weeks of a coronary procedure, and stent patients prescribed either drug within 2 weeks of stent placement in 1998. Substantial short-term use of ticlopidine and clopidogrel was found. The percentage of members with duration of use , 30 days ranged from 50.4% in 1996 to 56.9% in 1998 for ticlopidine and was 52.7% for clopidogrel. In 1998, 46% and 33% of ticlopidine and clopidogrel users, respectively, had a medical claim for a coronary procedure that fell within 2 weeks of a prescription. The rate was lower for Medicare beneficiaries. In 1998, 78% of stent patients filled a prescription for either drug within 2 weeks of stent implantation. Although little difference was found overall in the use of these agents across geographic regions, a higher proportion of stent patients in the Southeast were prescribed ticlopidine within this timeframe. The findings suggest that during the study time period ticlopidine and clopidogrel are frequently used off-label in association with percutaneous coronary revascularization procedures. These results were important in considering the overall benefit-risk profile. [source]


Satisfaction and Use of Prenatal Care: Their Relationship Among African-American Women in a Large Managed Care Organization

BIRTH, Issue 1 2003
Arden Handler DrPH
ABSTRACT:Background: Although many more mothers of almost all ethnic groups began prenatal care in the first trimester during the last decade, a significant number of low-income and minority women still fail to obtain adequate care in the United States,a failure that may be related to their dissatisfaction with the prenatal care experience. This study sought to examine the relationship between satisfaction with care and subsequent prenatal care utilization among African-American women using prospective methods. Methods: A sample of 125 Medicaid and 275 non-Medicaid African-American adult women seeking care through a large Midwest managed care organization were interviewed before or at 28 weeks' gestation at one of two prenatal care sites. Women were interviewed about personal characteristics, prenatal care experience, and ratings of care (satisfaction). Information about subsequent use of prenatal care was obtained through retrospective medical record review after delivery. Univariate and multivariable analyses examining the relationship between women's satisfaction and prenatal care use were conducted using a dichotomous measure of satisfaction and a continuous measure of utilization. Results: Women were highly satisfied with prenatal care, with an overall mean satisfaction score of 80.3. Non-Medicaid women were significantly (p < 0.05) less satisfied with their prenatal care (mean score, 79.1) than Medicaid women (mean score, 82.8), and the latter had significantly fewer visits on average than the former subsequent to the interview. Analyses showed no significant difference in subsequent utilization according to whether a woman had a high versus low level of satisfaction at the prenatal care interview. Conclusions: This study challenges the assumption that improving a woman's satisfaction with care will lead to an increase in the adequacy of her prenatal care utilization. Since this study was limited to African-American women and is the first prospective study of women's satisfaction with care and prenatal care utilization, the negative findings do not yet settle this area of inquiry. Monitoring women's satisfaction with prenatal care in both managed care and fee-for-service settings and working to improve those aspects of care associated with decreased satisfaction is warranted. (BIRTH 30:1 March 2003) [source]


Managed Care Incentives and Inpatient Complications

JOURNAL OF ECONOMICS & MANAGEMENT STRATEGY, Issue 1 2002
Philip A. Haile
Managed care organizations control costs through restrictions on patient access to specialized services, oversight of treatment protocols, and financial incentives for providers. We investigate possible effects of such practices on the care patients receive by studying frequencies of in-hospital complications. We find significant differences in complication rates between managed care and fee-for-service patients. We investigate the sources of this variation by comparing probabilities of complications among patients with different types of managed care coverage and patients treated in different hospitals. For several patient categories, the differences in outcomes we find appear to arise not from differential treatment of patients within hospitals or from heterogeneity in patients, but from variations in care across hospitals that tend to treat patients with different insurance types. [source]


Ethics in Managed Care and Pain Medicine

PAIN MEDICINE, Issue 2 2001
Jeffrey Livovich MD
The responsibility for ethical behavior in medical care has been described historically as evolving through 3 stages: personal responsibility, professional group responsibility, and organizational responsibility. Together these 3 forms provide a system of accountability that works better than any one form alone. Today we have added a fourth stage, societal responsibility, in which oversight of managed care practices is maintained by external review organizations. Managed care organizations and their medical directors can work with physicians, professional societies and oversight organizations to develop a working healthcare system that protects the ethical rights of individual patients and populations of patients. [source]


Social Justice or Market Justice?

PUBLIC HEALTH NURSING, Issue 3 2002
The Paradoxes of Public Health Partnerships with Managed Care
Public health is increasingly joining forces with managed care, yet the effect of this partnership on public health nursing (PHN) has received little scrutiny. The feasibility and consequences of a public,private alliance raise questions about whether the mission of public health can be sustained in a managed care system and whether managed care's approaches to health care are conducive to providing population-oriented care. Expanding the links between PHN and private organizations is both problematic and promising. Managed care organizations have much to offer, including coordination of services and comprehensive care. However, they may also restrict coverage and create bureaucratic obstacles to obtaining services. The growth of for-profit health care corporations evokes questions about ways in which concern for communities and populations collide with stockholder interests. The task for PHN is to recognize and to dialogue about these complexities so that nursing's voice can be heard as solutions to these dilemmas are created. [source]


Physician characteristics associated with prescription of inappropriate medications using Beers criteria

GERIATRICS & GERONTOLOGY INTERNATIONAL, Issue 4 2007
Hirohisa Imai
Background: The prescription of potentially inappropriate medications (PIM) for elderly patients represents a major problem. In the published work, various practice characteristics associated with physicians prescribing habits have been reported. However, existing data has shed little light on the characteristics of physicians who tend to prescribe PIM. We examined whether personal, professional or practice characteristics differ between physicians who prescribe PIM and those who do not. Methods: The subjects comprised primary care and general practice physicians. Physicians were identified from the pharmacy database of a managed care organization as having prescribed medications for Medicare patients over 65 years enrolled in a managed care plan. We adopted Beers criteria to describe the prevalence of PIM use. The physicians were divided into three groups according to number of PIM prescribed. To examine the extent of associations between all the physician-related characteristics studied, polychotomous logistic regression was conducted. Results: Physicians who prescribed one to five PIMs were 0.63 (95% confidence interval [CI], 0.41,0.98) times more likely to have publications than physicians who prescribed no PIM. Physicians who prescribed more than six PIM were 3.18 (95% CI, 2.05,4.95) times more likely to be certified by an internal medicine board, 0.48 (95% CI, 0.30,0.78) times more likely to have publications, and 1.84 (95% CI, 1.01,3.35) times more likely to be in solo practice than physicians who prescribed no PIM. Conclusion: In this study, we found three predictors of PIM prescribing incidence. Since the current study could only describe associations and not causality, further research is necessary. [source]


Alcohol Drinking Patterns and Health Care Utilization in a Managed Care Organization

HEALTH SERVICES RESEARCH, Issue 3 2004
Gary A. Zarkin
Objective. To estimate the relationship between current drinking patterns and health care utilization over the previous two years in a managed care organization (MCO) among individuals who were screened for their alcohol use. Study Design. Three primary care clinics at a large western MCO administered a short health and lifestyle questionnaire to all adult patients on their first visit to the clinic from March 1998 through December 1998. Patients who exceeded the National Institute on Alcohol Abuse and Alcoholism (NIAAA) guidelines for moderate drinking were given a more comprehensive alcohol screening using a modified version of the Alcohol Use Disorders Identification Test (AUDIT). Health care encounter data for two years preceding the screening visit were linked to the remaining individuals who responded to one or both instruments. Using both quantity,frequency and AUDIT-based drinking pattern variables, we estimated negative binomial models of the relationship between drinking patterns and days of health care use, controlling for demographic characteristics and other variables. Principal Findings. For both the quantity,frequency and AUDIT-based drinking pattern variables, current alcohol use is generally associated with less health care utilization relative to abstainers. This relationship holds even for heavier drinkers, although the differences are not always statistically significant. With some exceptions, the overall trend is that more extensive drinking patterns are associated with lower health care use. Conclusions. Based on our sample, we find little evidence that alcohol use is associated with increased health care utilization. On the contrary, we find that alcohol use is generally associated with decreased health care utilization regardless of drinking pattern. [source]


Managed Behavioral Health Care: An Instrument to Characterize Critical Elements of Public Sector Programs

HEALTH SERVICES RESEARCH, Issue 4 2002
M. Susan Ridgely
Objective. To develop an instrument to characterize public sector managed behavioral health care arrangements to capture key differences between managed and ,unmanaged" care and among managed care arrangements. Study Design. The instrument was developed by a multi-institutional group of collaborators with participation of an expert panel. Included are six domains predicted to have an impact on access, service utilization, costs, and quality. The domains are: characteristics of the managed care plan, enrolled population, benefit design, payment and risk arrangements, composition of provider networks, and accountability. Data are collected at three levels: managed care organization, subcontractor, and network of service providers. Data Collection Methods. Data are collected through contract abstraction and key informant interviews. A multilevel coding scheme is used to organize the data into a matrix along key domains, which is then reviewed and verified by the key informants. Principal Findings This instrument can usefully differentiate between and among Medicaid fee-for-service programs and Medicaid managed care plans along key domains of interest. Beyond documenting basic features of the plans and providing contextual information, these data will support the refinement and testing of hypotheses about the impact of public sector managed care on access, quality, costs, and outcomes of care. Conclusions. If managed behavioral health care research is to advance beyond simple case study comparisons, a well-conceptualized set of instruments is necessary. [source]


Ambulatory Use of Ticlopidine and Clopidogrel in Association with Percutaneous Coronary Revascularization Procedures in a National Managed Care Organization

JOURNAL OF INTERVENTIONAL CARDIOLOGY, Issue 3 2002
DEBORAH SHATIN PH.D.
The aim of this study was to quantify ambulatory use of ticlopidine and clopidogrel in association -with percutaneous coronary revascularization procedures (PTCA, atherectomy, stent) in a national managed care organization. Retrospective administrative claims data over a 3-year period (1996,1998) from 12 UnitedHealth Group-affiliated health plans in four geographic regions were collected. Pharmacy and medical claims data were used to determine the patients exposed to ticlopidine and clopidogrel between January 1, 1996 and December 31, 1998, the duration of use, prescriptions within 2 weeks of a coronary procedure, and stent patients prescribed either drug within 2 weeks of stent placement in 1998. Substantial short-term use of ticlopidine and clopidogrel was found. The percentage of members with duration of use , 30 days ranged from 50.4% in 1996 to 56.9% in 1998 for ticlopidine and was 52.7% for clopidogrel. In 1998, 46% and 33% of ticlopidine and clopidogrel users, respectively, had a medical claim for a coronary procedure that fell within 2 weeks of a prescription. The rate was lower for Medicare beneficiaries. In 1998, 78% of stent patients filled a prescription for either drug within 2 weeks of stent implantation. Although little difference was found overall in the use of these agents across geographic regions, a higher proportion of stent patients in the Southeast were prescribed ticlopidine within this timeframe. The findings suggest that during the study time period ticlopidine and clopidogrel are frequently used off-label in association with percutaneous coronary revascularization procedures. These results were important in considering the overall benefit-risk profile. [source]


The course and correlates of high hospital utilization in sickle cell disease: Evidence from a large, urban Medicaid managed care organization,

AMERICAN JOURNAL OF HEMATOLOGY, Issue 10 2009
C. Patrick Carroll
Although most patients with sickle cell disease (SCD) are hospitalized infrequently and manage painful crises at home, a small subpopulation is frequently admitted to emergency departments and inpatient units. This small group accounts for the majority of health care expenses for patients with SCD. Using inpatient claims data from a large, urban Medicaid MCO for 5 consecutive years, this study sought to describe the course of high inpatient utilization (averaging four or more admissions enrolled per year for at least 1 year) in members with a diagnosis of SCD and a history of hospitalizations for vaso-occlusive crisis. High utilizers were compared with the other members with SCD on demographics, medical and psychiatric comorbidity, and use of other health care resources. Members who were high utilizers had more diagnostic mentions of sickle cell complications than low utilizers. However, the pattern of high inpatient utilization was likely to moderate over successive years, and return to the pattern after moderation was uncommon. Despite this, a small subpopulation engaged in exceptional levels of inpatient utilization over multiple years. Am. J. Hematol., 2009. 2009 Wiley-Liss, Inc. [source]


Validity of computerized diagnoses, procedures, and drugs for inflammatory bowel disease in a northern California managed care organization,,

PHARMACOEPIDEMIOLOGY AND DRUG SAFETY, Issue 11 2009
Liyan Liu MD
Abstract Purpose Resources for studying inflammatory bowel disease (IBD) are needed in evaluations of drug safety including traditional drugs and new biologics agents. We developed an IBD registry, with ascertainment from computerized visit information. Objective We sought to characterize the positive predictive value (PPV) of IBD case-finding using computerized data compared with chart review. Methods We identified 2906 persons aged 89 years or younger with one or more IBD diagnoses in computerized visit data during the period of 1996,2002. The diagnosis of IBD was confirmed through chart review. Adopting chart review as the gold standard, the validity of computerized encounter data to determine IBD was estimated. Results Among the 2906 study subjects with one or more ICD-9 diagnosis codes of 555 or 556 in computerized data, 81% were confirmed as having IBD by chart review. Defining cases as those who underwent two or more visits without regard to diagnostic procedures or drug utilization maximized the correct classification of cases (PPV, 95%). Conclusions The quality of IBD diagnoses in computerized data is adequate to meet the aims of a wide range of research studies. Copyright 2009 John Wiley & Sons, Ltd. [source]


Satisfaction and Use of Prenatal Care: Their Relationship Among African-American Women in a Large Managed Care Organization

BIRTH, Issue 1 2003
Arden Handler DrPH
ABSTRACT:Background: Although many more mothers of almost all ethnic groups began prenatal care in the first trimester during the last decade, a significant number of low-income and minority women still fail to obtain adequate care in the United States,a failure that may be related to their dissatisfaction with the prenatal care experience. This study sought to examine the relationship between satisfaction with care and subsequent prenatal care utilization among African-American women using prospective methods. Methods: A sample of 125 Medicaid and 275 non-Medicaid African-American adult women seeking care through a large Midwest managed care organization were interviewed before or at 28 weeks' gestation at one of two prenatal care sites. Women were interviewed about personal characteristics, prenatal care experience, and ratings of care (satisfaction). Information about subsequent use of prenatal care was obtained through retrospective medical record review after delivery. Univariate and multivariable analyses examining the relationship between women's satisfaction and prenatal care use were conducted using a dichotomous measure of satisfaction and a continuous measure of utilization. Results: Women were highly satisfied with prenatal care, with an overall mean satisfaction score of 80.3. Non-Medicaid women were significantly (p < 0.05) less satisfied with their prenatal care (mean score, 79.1) than Medicaid women (mean score, 82.8), and the latter had significantly fewer visits on average than the former subsequent to the interview. Analyses showed no significant difference in subsequent utilization according to whether a woman had a high versus low level of satisfaction at the prenatal care interview. Conclusions: This study challenges the assumption that improving a woman's satisfaction with care will lead to an increase in the adequacy of her prenatal care utilization. Since this study was limited to African-American women and is the first prospective study of women's satisfaction with care and prenatal care utilization, the negative findings do not yet settle this area of inquiry. Monitoring women's satisfaction with prenatal care in both managed care and fee-for-service settings and working to improve those aspects of care associated with decreased satisfaction is warranted. (BIRTH 30:1 March 2003) [source]


Effect of Ethnicity on Denial of Authorization for Emergency Department Care by Managed Care Gatekeepers

ACADEMIC EMERGENCY MEDICINE, Issue 3 2001
Robert A. Lowe MD
Abstract. Objective: After a pilot study suggested that African American patients enrolled in managed care organizations (MCOs) were more likely than whites to be denied authorization for emergency department (ED) care through gatekeeping, the authors sought to determine the association between ethnicity and denial of authorization in a second, larger study at another hospital. Methods: A retrospective cohort design was used, with adjustment for triage score, age, gender, day and time of arrival at the ED, and type of MCO. Results: African Americans were more likely to be denied authorization for ED visits by the gatekeepers representing their MCOs even after adjusting for confounders, with an odds ratio of 1.52 (95% CI = 1.18 to 1.94). Conclusions: African Americans were more likely than whites to be denied authorization for ED visits. The observational study design raises the possibility that incomplete control of confounding contributed to or accounted for the association between ethnicity and gatekeeping decisions. Nevertheless, the questions that these findings raise about equity of gatekeeping indicate a need for additional research in this area. [source]


Improving Care for Minorities: Can Quality Improvement Interventions Improve Care and Outcomes For Depressed Minorities?

HEALTH SERVICES RESEARCH, Issue 2 2003
Controlled Trial, Results of a Randomized
Objective. Ethnic minority patients often receive poorer quality care and have worse outcomes than white patients, yet practice-based approaches to reduce such disparities have not been identified. We determined whether practice-initiated quality improvement (QI) interventions for depressed primary care patients improve care across ethnic groups and reduce outcome disparities. Study Setting. The sample consists of 46 primary care practices in 6 U.S. managed care organizations; 181 clinicians; 398 Latinos, 93 African Americans, and 778 white patients with probable depressive disorder. Study Design. Matched practices were randomized to usual care or one of two QI programs that trained local experts to educate clinicians; nurses to educate, assess, and follow-up with patients; and psychotherapists to conduct Cognitive Behavioral Therapy. Patients and physicians selected treatments. Interventions featured modest accommodations for minority patients (e.g., translations, cultural training for clinicians). Data Extraction Methods. Multilevel logistic regression analyses assessed intervention effects within and among ethnic groups. Principal Findings. At baseline, all ethnic groups (Latino, African American, white) had low to moderate rates of appropriate care and the interventions significantly improved appropriate care at six months (by 8,20 percentage points) within each ethnic group, with no significant difference in response by ethnic group. The interventions significantly decreased the likelihood that Latinos and African Americans would report probable depression at months 6 and 12; the white intervention sample did not differ from controls in reported probable depression at either follow-up. While the intervention significantly improved the rate of employment for whites and not for minorities, precision was low for comparing intervention response on this outcome. It is important to note that minorities remained less likely to have appropriate care and more likely to be depressed than white patients. Conclusions. Implementation of quality improvement interventions that have modest accommodations for minority patients can improve quality of care for whites and underserved minorities alike, while minorities may be especially likely to benefit clinically. Further research needs to clarify whether employment benefits are limited to whites and if so, whether this represents a difference in opportunities. Quality improvement programs appear to improve quality of care without increasing disparities, and may offer an approach to reduce health disparities. [source]


A Comparison of Two Methods for Identifying Frail Medicare-Aged Persons

JOURNAL OF AMERICAN GERIATRICS SOCIETY, Issue 3 2002
Kathleen K. Brody BSN
This article compares the efficacy of two screening methods to identify frail Medicare-aged persons using self-report questionnaire data: a clinical judgment method developed by nurse and social worker professionals in a community-based long-term care department and an empirical research method previously developed by the Center for Health Research using computer formulas and stepwise logistic regression coefficients. A sub-aim was to see whether the empirical method proved robust over time by measuring aggregate utilization and mortality in frail and nonfrail cohorts, which would increase the interest of physicians, managed care organizations, and other agencies providing service to Medicare beneficiaries. [source]


Rural-Urban Differences in Health Risks, Resource Use and Expenditures Within Three State Medicaid Programs: Implications for Medicaid Managed Care

THE JOURNAL OF RURAL HEALTH, Issue 1 2002
Janet M. Bronstein Ph.D.
This study uses Medicaid claims data for income-eligible enrollees in California, Georgia and Mississippi to compare expenditures, resource usage and health risks between residents of rural and urban areas of the states. Resource use is measured using the Resource Based Relative Value Scale (RBRVS) system for professional services, hospital days and outpatient facility visits; it also is valued at private insurance reimbursement rates for the states. Health risks are measured using the diagnosis-based Adjusted Clinical Group system. Resource use is compared on a risk-adjusted basis with the use of urban Medicaid enrollees as the benchmark. We find that actual expenditures for rural care users are lower than for urban care users. However, because the proportion of Medicaid enrollees who use care is higher in rural than in urban areas in all three states, expenditures per rural enrollee are not consistently lower. Case mix is more resource intensive for rural compared to urban residents in all three states. Although resource usage is not systematically lower owerall for rural enrollees, on a risk-adjusted basis they tend to use less hospital resources than urban enrollees. Capitation rates based on historical per enrollee expenditures would not appear to under-reimburse managed care organizations for the care of rural as opposed to urban residents in the study states. [source]