Applying Managed Care Techniques in Traditional Medicare

Health Affairs

Volumn 16, Issue 5, 1997, Pages 44-57

  Fox, Peter D ^a  

^a NONE

Author keywords

[No Author keywords available]

Indexed keywords

ARTICLE; ECONOMICS; HEALTH CARE QUALITY; HEALTH INSURANCE; HUMAN; MEDICAL FEE; MEDICARE; ORGANIZATION AND MANAGEMENT; POLITICS; UNITED STATES;

FEE-FOR-SERVICE PLANS; HUMANS; MANAGED CARE PROGRAMS; MEDICARE; POLITICS; QUALITY OF HEALTH CARE; UNITED STATES;

EID: 0005697423     PISSN: 02782715     EISSN: None     Source Type: Journal    
DOI: 10.1377/hlthaff.16.5.44     Document Type: Article

References (25)

1. The distinction between price and utilization is at times blurred in that some policy changes affect both price and utilization. A good example is the Medicare prospective payment system (PPS), which reimburses hospitals principally on a per case basis, thereby encouraging hospitals to constrain the use of ancillary services and lengths-of-stay.
2. Health Care Financing Administration, 1996 Data Compendium (Baltimore: HCFA, 1997), 46; and HCFA, Office of Managed Care, Medicare Managed Care Contract Report (issued monthly).
3. Health Care Financing Administration, 1996 Data Compendium (Baltimore: HCFA, 1997), 46; and HCFA, Office of Managed Care, Medicare Managed Care Contract Report (issued monthly).
4. Examples of population-based measures are reflected in the Health Plan Employer Data and Information Set (HEDIS) measures developed by the National Committee for Quality Assurance (NCQA).
5. E.L. Hannan et al., "Improving the Outcomes of Coronary Artery Bypass Surgery in New York State," Journal of the American Medical Association (9 March 1994): 761-766. The authors argue for combining Medicare with other data for purposes of assessing quality. See E.L. Hannan et al., "Using Medicare Claims Data to Assess Provider Quality for CABG Surgery: Does It Work Well Enough?" Health Services Research (February 1997): 659-768.
6. E.L. Hannan et al., "Improving the Outcomes of Coronary Artery Bypass Surgery in New York State," Journal of the American Medical Association (9 March 1994): 761-766. The authors argue for combining Medicare with other data for purposes of assessing quality. See E.L. Hannan et al., "Using Medicare Claims Data to Assess Provider Quality for CABG Surgery: Does It Work Well Enough?" Health Services Research (February 1997): 659-768.
7. M.R. Chassin, E.L. Hannan, and B.A. DeBuono, "Benefits and Hazards of Reporting Medical Outcomes Publicly," The New England Journal of Medicine (8 February 1996): 394-398.
8. See, for example, N.A. Hanchak et al., "The Effectiveness of an Influenza Vaccination Program in an HMO Setting," American Journal of Managed Care 2, no. 6 (1996): 661-666.
9. One shortcoming is that beneficiaries may receive inoculations through community organizations that do not submit claims to Medicare.
10. See, for example, Dartmouth Medical School, Center for Evaluative Clinical Services, The Dartmouth Atlas of Health Care, Part IV (American Hospital Association, 1996), 59-79.
11. Wide variability exists in the relationship between Medicare payments and what providers will accept from managed care plans. For example, in some market areas many specialists accept payments that are 20 percent or more below Medicare fee levels, whereas in most markets Medicare payment levels are viewed as low. This approach would be designed, in part, to achieve savings in markets where Medicare pays more than private health plans do.
12. R.E. Hurley, D.A. Freund, and J.E. Paul, Managed Care in Medicaid: Lessons for Policy and Program Design (Ann Arbor, Mich.: Health Administration Press, 1993). One caveat regarding the interpretation of research results is that most of the Medicaid experience relates to the Aid to Families with Dependent Children (AFDC), not the Supplemental Security Income (SSI) (that is, aged and disabled) population.
13. G.S. Chulis et al., "Health Insurance and the Elderly: Data from the Medicare Current Beneficiary Survey," Health Care Financing Review (Spring 1993): 163-181.
14. For examples of a variety of interventions used by HMOs geared to a chronically ill population, see A.M. Kramer, P.D. Fox, and N. Morgenstern, "Geriatric Care Approaches in Health Maintenance Organizations," Journal of the American Geriatric Society 40, no. 10 (1992): 1055-1067; P.D. Fox and T. Fama, eds., Managed Care and Chronic Illness: Challenges and Opportunities (Gaithersburg, Md.: Aspen Publishers, 1996); and P.D. Fox and T. Fama, "Managed Care and the Elderly: Performance and Potential," Generations (Summer 1996): 31-36. HMOs vary widely in the extent to which they have mounted programs that are focused specifically on elderly or disabled populations.
15. For examples of a variety of interventions used by HMOs geared to a chronically ill population, see A.M. Kramer, P.D. Fox, and N. Morgenstern, "Geriatric Care Approaches in Health Maintenance Organizations," Journal of the American Geriatric Society 40, no. 10 (1992): 1055-1067; P.D. Fox and T. Fama, eds., Managed Care and Chronic Illness: Challenges and Opportunities (Gaithersburg, Md.: Aspen Publishers, 1996); and P.D. Fox and T. Fama, "Managed Care and the Elderly: Performance and Potential," Generations (Summer 1996): 31-36. HMOs vary widely in the extent to which they have mounted programs that are focused specifically on elderly or disabled populations.
16. For examples of a variety of interventions used by HMOs geared to a chronically ill population, see A.M. Kramer, P.D. Fox, and N. Morgenstern, "Geriatric Care Approaches in Health Maintenance Organizations," Journal of the American Geriatric Society 40, no. 10 (1992): 1055-1067; P.D. Fox and T. Fama, eds., Managed Care and Chronic Illness: Challenges and Opportunities (Gaithersburg, Md.: Aspen Publishers, 1996); and P.D. Fox and T. Fama, "Managed Care and the Elderly: Performance and Potential," Generations (Summer 1996): 31-36. HMOs vary widely in the extent to which they have mounted programs that are focused specifically on elderly or disabled populations.
17. J.G. Zimmer et al., "Nursing Homes as Acute Care Providers: A Pilot Study of Incentives to Reduce Hospitalizations," Journal of the American Geriatric Society 36, no. 2 (1988): 124-129.
18. See, for example, R.L. Kane et al., "Improving Primary Care in Nursing Homes," Journal of the American Geriatric Society 39, no. 4 (1991): 359-367.
19. See, for example, J.B. Burl, A. Bonner, and M. Rao, "Demonstration of the Cost-Effectiveness of a Nurse Practitioner/Physician Team in Long-Term Care Faculties," HMO Practice (December 1994): 157-161. David Reuben at the University of California, Los Angeles (UCLA), is completing a study of three HMOs with enhanced primary care for long-stay nursing home residents; preliminary findings are encouraging.
20. E.H. Wagner, B.T. Austin, and M. Von Korff, "Improving Outcomes in Chronic Illness," in Managed Care and Chronic Illness.
21. Center for Health Program Development and Management, University of Maryland, Baltimore County, State of Maryland Diabetes Program (DCP), An Independent Evaluation of the Waiver Granted to the Maryland Department oF Health and Mental Hygiene under Sections 1915(b)(1) and (3) of the Social Security Act (Baltimore: UMBC, 13 September 1995).
22. Center for Health Program Development and Management, University of Maryland, Baltimore County, Maryland Medicaid High Cost User Initiative: Case Management and Cost Savings Annual Report, CY 1995 (Baltimore: UMBC, March 1996). The savings reported are based on estimates of the costs that would have occurred absent the intervention rather than on the experience of a control group. Notwithstanding limitations in the methodology, the order of magnitude of the savings is impressive.
23. See, for example, MW. Rich et al., "A Multidisciplinary Intervention to Prevent the Readmission of Elderly Patients with Congestive Heart Failure," The New England Journal of Medicine (2 November 1995): 1190-1195.
24. There has always been a lack of uniformity because of (1) variations in the availability of medical resources, and (2) differences among fiscal intermediaries in the interpretation of coverage and other rules. However, these differences are smaller than those caused by geographic variations in HMO premiums and benefits, which now exceed $1,000 per beneficiary per year.
25. J.T. Pacala et al., "Case Management of Older Adults in Health Maintenance Organizations," Journal of the American Geriatric Society 43, no. 5 (1995): 538-542.