Managed care liability update

As the volume of litigation involving managed care grows, the liability issues become clearer. For example, recent decisions demonstrate that failure to provide access to qualified physicians, failure to process claims appropriately, denial of claims and undue delay of treatment can and do lead to liability. Moreover, the federal Employment Retirement Income Security Act of 1974 (ERISA) won't protect the managed care providers, and physicians may sue the managed care organization if its policies or agents open them to liability.     

Managed obstetrical care

BACKGROUND: Infertility is common in Africa, but virtually no data exist on HIV prevalence among infertile women. Mainly anthropological studies in Africa have shown that infertile women have higher risks of marital instability and possibly also have more sexual partners than fertile women. METHOD: This study was conducted in a hospital in northwest Tanzania during 1994 and 1995. Women presenting themselves with infertility problems to the outpatient clinic were interviewed, examined and blood was drawn. Women who came to deliver in the hospital, excluding primiparae, were taken as a control group. The analysis was limited to women > or = 24 years. In total 154 infertile and 259 fertile women were included in the study. RESULTS: HIV prevalence was markedly higher among infertile women than among fertile women: 18.2% and 6.6% respectively (adjusted odds ratio [OR] for age, residence and occupation 2.7; 95%-confidence interval [CI]: 1.4-5.3). Data on past sexual behaviour showed that infertile women had more marital breakdowns, more lifetime sexual partners and a higher level of exposure to sexually transmitted diseases (STD). CONCLUSION: Women with fertility problems appear to have higher HIV prevalence, which justifies more attention for such women in the context of AIDS programmes. In addition, caution is needed when using sentinel surveillance data from antenatal clinics to monitor HIV prevalence.     

Managed care and unintended pregnancy

This article assesses the adequacy of coverage of contraceptive services and supplies for US women in the various types of managed care plans, with special attention to Medicaid. Between 1993 and 1995, the percent of insured private-sector employees enrolled in managed care plans rose from 51% to 73%. By 1996, the health care of 40% of low-income Medicaid recipients was also under managed care administration. Although 84% of managed care plans cover oral contraceptives--a rate substantially higher than that for traditional indemnity plans, several logistic factors impede access to this and other reproductive health benefits. The requirement of preauthorization may delay access to care when timely presentation is essential to the prevention of unwanted pregnancy. Some plans restrict members to one visit per year with an obstetrician-gynecologist. Coordination of an enrollee's total health care through the primary care physician can raise confidentiality problems for those who seek sensitive reproductive health services. There are fewer restrictions on the access of Medicaid recipients to family planning providers and services, but treatment of sexually transmitted diseases may not be part of the reproductive health package. The explosion of managed care onto the US health care market has led to public sector regulation legislation--a process that is proceeding in a piecemeal rather than comprehensive way. Because of the importance of reproductive health care to the lives of women, communities, and the broader society, more systematic action on this front is essential.     

Managed care contracts and negotiations

This article examines the key provisions which should be focused on when reviewing managed care contracts. It offers guidance on how gastroenterologists can negotiate more favorable terms and avoid common contracting pitfalls. The article also highlights specific issues applicable to capitated and other risk-sharing arrangements.     

Managed care and reproductive health

Managed care poses special challenges to midwives providing reproductive health care. This is owing to the sensitive nature of issues surrounding reproductive health and aspects of managed care that may impede a woman's ability to obtain continuous, confidential, and comprehensive care from the provider of her choice. Variations across payers (ie, Medicare, Medicaid, and commercial insurers) regarding covered benefits and reimbursement of midwifery services also may create obstacles. Furthermore, some physicians and managed care organizations are embracing policies that threaten the ability of midwives to function as primary health care providers for women. Despite these hurdles, midwives have the potential to remain competitive in the new marketplace. This article underscores the importance of being knowledgeable about legislation and policy issues surrounding the financing of midwifery services, quality performance measurement for HMOs as they pertain to reproductive health, and discussions regarding which clinicians should be defined as primary care providers.     

Managed care and public health

BACKGROUND: The effect on cell viability of smoke produced during high-frequency electro-surgery has not been previously reported. The aim of this study was to produce smoke in vitro, in a closed environment similar to that encountered in minimal access surgery, and to test its cytotoxic effects on cultured cells. METHODS: Pig liver was cut repeatedly with an electro-surgical hook knife, and the smoke generated was collected and equilibrated with cell culture medium. MCF-7 human breast carcinoma cells were exposed briefly to various dilutions of this medium and tested for clonogenicity. RESULTS: Electro-surgical smoke produced in a helium environment reduced the clonogenicity of the MCF-7 human breast carcinoma cells in a dose-dependent manner, falling to 30% when the cells were exposed to undiluted medium for 15 minutes. CONCLUSIONS: We conclude that electro-surgical smoke is cytotoxic. The sublethal effects at lower dilutions are currently being investigated.     

Managed mental health care redux.

Comments on the series on managed health care (MHC) edited by R. L. Lowman (see record 1991-16482-001) that advocated restrictions in MHC to reduce employer costs. It is argued that restricting outpatient coverage is not mandated by economic necessity, and that it creates ethical and clinical risks and ill will toward funders by patients and therapists. Alternative MHC services are suggested. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Managed care glossary: update II

The paper presents differential-diagnostic signs of phobic disorders of different etiology. Acute episodes of depersonalization preceding phobias and fears arising during the first age crisis are considered as some diagnostic signs of endogenous phobias. The significant criteria for diagnosis of psychogenic phobias are anxious suspiciousness, affective instability, susceptibility, spontaneity of reactivity and the presence of personally important psychic trauma. An autonomic paroxysm caused by alcoholic situation in exogenic organic pathology (alcoholism) was transformed quite fast into some senestopathias, which themselves maintained the of fear. The relationships of phobias and depressions in endogenous disorders was different: in slow-progredient variations of the disease depression resulted in a decrease of the manifestations of the phobias, and vice versa; in shift-like variations depression is an independent syndrome in the depressive-phobic complex. Depressions and phobias are closely connected in psychogenic phobias, they complicated and developed in parallel. In exogenic-organic phobias both affective disorders and phobias had a paroxysmal character and transformed into dysphorias.     

Managed care may crunch GME programs

The paper presents the results of examination of 61 patients aged 7-15 years with impulse-control disorders (drive) within psychopathy-like syndrome in slow progredient schizophrenia or in residual-organic disorders of CNS. 4 types of impulse-control disorders were identified: 1) drives concerning mainly instincts' disorders (enhanced physiologic drives, perversive physiologic drives); 2) drives due to disorders of will (the impulsive drives, the precursors of the impulsive drives); 3) the obsessive drives; 4) "social" forms of altered drives. In the group of schizophrenic patients prevailed disturbances of drives concerning the instinctive sphere (97.9%) and seldom "social" forms (2.1%) were ovserwed. In the patients with residual-organic CNS damage the "social" forms were quite frequent (50%) as well as disorders of will (45.8%), but disorders of instincts (4.2%) occurred rarely. Children and adolescent had often incomplete drives in the form of precursors of the impulsive drives.