State regulation of managed care: the impact on children

As more and more children enroll in managed care, states have responded to concerns expressed by their constituents by passing legislation and developing credentialing requirements to assist families with children in receiving appropriate care from managed care plans. Although most of the legislation and credentialing requirements apply to the population generally, a few provisions apply specifically to children. The legislation and credentialing requirements attempt to improve both access to medical care and the quality of care by enacting access-to-care and quality-of-care provisions, reducing the financial incentives for providers to offer inappropriate care, and providing families with more information about their choices and opportunities to redress their grievances. Although there is no empirical evidence, analysis of similar types of legislation suggests that certain approaches will be more successful than others; one obvious indicator of success is the ability of the regulatory agency to develop clear, unambiguous, enforceable rules. Existing legislation varies widely across states in terms of the issues addressed and the specificity of the laws. For the most part, this legislation has been piecemeal, addressing specific issues as they arise. In the long run, state legislatures may not have the time or the expertise to regulate the managed care industry, and other regulatory bodies may be better equipped to address concerns about managed care. If utilized, however, existing regulatory bodies, which historically monitored fee-for-service medicine, will need to be redesigned to monitor managed care.     

Implementing clinical paths in a managed care environment

The survival of health care institutions depends upon a delivery system focusing on appropriate use of resources and controlling length of stay while monitoring clinical progress toward identified outcomes. Using a clinical path as a tool for managing resources, research activities, continuous quality improvement, and increased collaborative practice can enhance the professional practice environment and benefit patient care.     

Child and adolescent psychological assessment: Current clinical practices and the impact of managed care.

Which psychological testing measures are clinical child and adolescent psychologists most commonly using? How has managed care influenced the practice of assessment for these professionals? This study provides survey data from 162 child practitioners employed in independent practice and in hospital, outpatient, and school-based settings throughout the United States. The results demonstrate marked consistency with recent surveys of clinicians working with adults, and a list of the 30 most frequently utilized measures is provided. Over 40% of the sample reported significant limitations in psychological testing due to managed-care policies. Strategies for maintaining an assessment practice are discussed. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

The impact of managed health care on predoctoral internship sites: A national survey.

Little empirical research has identified the impact of managed health care (MHC) on various types of predoctoral internship sites. Thus, the authors examined (a) the extent to which MHC affected such sites, (b) the types of sites most affected by MHC, and (c) internship training directors' (ITDs') perceptions of MHC's influence on specific issues in their sites. Overall, ITDs indicated that MHC had generally little impact on internship agencies to date. However, ongoing monitoring of MHC's effects on internship sites is warranted. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

The gynecological care experience of adult survivors of childhood sexual abuse: a preliminary investigation

The gynecological care experiences of 44 adult survivors of childhood sexual abuse and 30 non-abused controls were investigated and compared. On a self-administered survey, survivors rated the gynecological care experience more negatively than the controls, experienced more intensely negative feelings, and reported being more uncomfortable during almost every stage of the gynecological examination than did the controls. Survivors also reported more trauma-like responses during the gynecological examination, including overwhelming emotions, intrusive or unwanted thoughts, memories, body memories, and feelings of detachment from their bodies. Eighty-two percent of the survivors in the sample had never been asked about a history of sexual abuse or assault by a gynecological care provider, despite clear evidence from this study that such information would be relevant to their care. Implications of the study's findings for gynecological care practice and training are explored, and questions for future research are discussed.     

The impact of physician involvement in managed care on efficient use of hospital resources

OBJECTIVES: This research assesses the impact of managed care on the physician's efficient use of hospital resources. It examines three questions. (1) Does a higher percentage and volume of managed care patients in the physician's hospital practice lead to more efficient utilization? (2) Do physicians shift cost to nonmanaged care patients in an effort to compensate for lower reimbursement for managed care patients? (3) Are there threshold effects in the percentage and volume of managed care patients treated by physicians? METHODS: The study combines patient discharge data from the state of Arizona with physician and hospital data for a 2-year period. Random effects maximum likelihood (REML) regressions were performed for four different diagnosis classifications to examine the effect of the physician's managed care caseload on mean-adjusted charges and length of stay. RESULTS: The findings suggest that physicians with high percentages and volumes of managed care patients in their hospital practice are more efficient in using hospital resources. The findings also suggest that physicians may compensate for the lower reimbursement from managed care patients by increasing their resource use among non-health maintenance organization patients. CONCLUSIONS: Finally, there appears to be a threshold effect of managed care activity on the physician's hospital utilization in one of the conditions studied.     

Single-participant research design: Bringing science to managed care.

The ongoing transition to managed health care continues to have repercussions for health care providers, perhaps the most important of which is an emphasis on accountability for demonstrating the usefulness of clinical interventions. This requirement places a premium on intervention research and highlights the historically strained relationship between psychological research and professional practice. In the midst of this challenge, researchers have increasingly criticized the logic and practice of traditional null hypothesis significance testing. This article describes the history, epistemology, and advantages of single-participant research designs for behavioral scientists and professionals in clinical settings. Although its lack of correspondence with the Fisherian tradition has precluded widespread adoption, the single-participant alternative features a design power and flexibility well suited to both basic science and applied research. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

The effects of research, managed care and professional relations on the chiropractic profession

The health care professions are in a period of rapid change, and chiropractic, because it is a relatively young profession, is experiencing change at an even more rapid pace. The changes in the chiropractic profession will be dictated in large measure by the effects of future research, managed care and the professional relationship established between the chiropractic profession and other health care professions. In this article, these effects are discussed by reviewing the past history of chiropractic, the present status and future implications.     

Nurse managed occupational health services without on-site clinical care delivery: a case example

1. In this program management/community network model of occupational health services, the occupational health nurse is responsible for managing program development and implementation, with vendors providing the clinical services. 2. Occupational health nurses' primary areas of responsibility are occupational health, disability case management, ergonomics, and health promotion. 3. Successful management of program outcomes requires the occupational health nurse to continually assess employee/business needs, maintain communication with employees and management, and partner with the environmental, health, and safety team, other functional work groups, and vendors. 4. Effective management of contracts becomes critical to the process beginning with clear service requirements through the delivery of quality services.     

Casemix adjustment of managed care claims data using the clinical classification for health policy research method

OBJECTIVES: The objective of this study was to explore the use of the Clinical Classification for Health Policy Research (CCHPR) as a casemix adjustment method for examining physician practice patterns. METHODS: The data source was 2 years of administrative claims from an 86,000 member health maintenance organization in southeastern Michigan. The CCHPR version 2 algorithm, which is in the public domain, was used to assign each claim to one of 260 clinical categories. CCHPR and age-sex categories were used as explanatory variables in multiple linear regression models with approved claims payments in dollars as the outcome variable. Regressions were performed retrospectively for 1994 and 1995, and with 1994 claims' history to predict 1995 utilization. Similar regressions were performed with age-sex categories alone, and also with the ambulatory diagnostic groups. RESULTS: The adjusted R2 value of the retrospective regression models for total approved dollars was 0.42 for both study years when CCHPR categories were used. In contrast, age-sex explanatory variables alone achieved an R2 of 0.02. CONCLUSIONS: The CCHPR method appears to be a promising tool to understand variability in physician resource utilization in managed care.     

The primary care physician and managed care

I have explored the major options open to PCPs. There are multiple variations on these themes. While the Connecticut market is fluid, one thing is clear, the solutions will vary from place to place. Health-care reorganization is a local phenomenon. Individual doctor groups can have a major influence on the direction of their local market. The future is uncertain, but whatever happens in Connecticut it will be evolutionary. PCPs must understand the realities of the current marketplace and plan a strategy to work with those realities to achieve their long-term goals. The choices we make today will have ramifications flowing far into future decades. PCPs and their patients will have to live with the consequences of these decisions. Please choose wisely.     

Clinical and economic impact of implementing a comprehensive diabetes management program in managed care

Diabetes mellitus places a significant burden on the U.S. healthcare system. Because of the potential to reduce diabetic complications and costs through intensive management, diabetes has become a primary target for disease management programs. We performed a retrospective analysis of short-term baseline and follow-up clinical, economic, and member and provider satisfaction data from approximately 7,000 people with diabetes being treated through seven managed care plans using Diabetes Treatment Centers of America's Diabetes NetCare, (Nashville, TN), a comprehensive diabetes management program. Our analysis indicates that Diabetes NetCare achieved gross economic adjusted savings of $50 per diabetic member per month (12.3%), with gross unadjusted savings of $44 (10.9%) per diabetic member per month. Hospital admissions per 1,000 diabetic member years decreased by 18%, and bed days fell by 21%. Patients with diabetes were more likely to get HbAlc tests, foot exams, eye exams, and cholesterol screenings while enrolled in the program. These data suggest that implementation of a comprehensive healthcare management program for people with diabetes can lead to substantial improvements in costs and clinical outcomes in the short-term. It is expected that improvements will increase over time, with continuing improvements in health status and a reduction in the number of future diabetic complications.     

The ethics of managed care: Part 3--Toward a common vision

A common set of values is one of the primary unifying elements of any systematized group. The moral crisis in health care today has more to do with value dis-integration than economic dis-array. The use of resource allocation mechanisms like managed care expand the needs of conscience with those of man-willed choice. If health professionals are to meet the ethical challenges of "managed care," they must start by reminding themselves of what the scientific and ethical commitments both promise and imply.     

The dilemma of managed care.

Responds to the article by L. S. Brown (see record 84-21642) regarding managed care and false memory movement issues in social justice-oriented psychology. The current author argues that Brown abandoned psychologists be declining to think through how responsible and ethical people can work their way out of binds. Buchholz also contends that a greater call to unity and action among psychologists is needed to fight the dehumanizing and threatening effects of the HMOs and insurance companies on mental health service delivery. (PsycINFO Database Record (c) 2010 APA, all rights reserved)