Managed care quarterly最新文献

This study is a descriptive analysis of the financial performance of licensed managed care plans that participate in Medicaid by ownership, provider-sponsorship, and the level of Medicaid focus and Medicaid enrollment. Using 2001 Interstudy data, health plan financial data for the Medicaid product line are analyzed on a national level for individual plans. Using SEC 10-K financial filings, company level analysis of two publicly traded, Medicaid-focused, managed care plans are analyzed as well. The analysis found that for-profit and non-profit plans had similar profit margins; however, for-profit plans incurred higher administrative costs ratios and lower medical benefits ratio. Plans with higher Medicaid enrollment had higher medical benefits ratios, while both provider-sponsored and non-provider sponsored plans had similar profit margins. Finally, publicly traded Medicaid focused plans achieved profit margins considerably higher than other Medicaid-focused plans.

Medicaid is a cornerstone of this country's health care system, covering over 50 million people and supplying one in five health care dollars in the United States. Medicaid is again a contested issue in state capitols, where states facing sluggish revenues target Medicaid since it is the second largest and fastest growing component of state spending. Managed care was the policy tool many states embraced in order to slow Medicaid spending, and while managed care has had some successes in improving Medicaid services, it has not met states' expectations for cost savings. This analysis explores several reasons why these savings have not been realized, and proposes policy reforms for state Medicaid programs that would make Medicaid coverage more stable, thereby increasing the ability of managed care plans and network providers to work with Medicaid beneficiaries to change patterns of care and realize real savings.

Two interrelated problems are included among the causes of managed care woes: the dramatic increase in unhealthy lifestyles together with the results these have had on health services utilization and expenditures; and the dramatic increase in consumer demand for "lifestyle" or quality of life (QoL) enhancing products and services. Together these are helping to drive managed care toward a crisis, in both commercial and government-sponsored insurance survival prospects. Aside from the frequently mentioned problem of our aging population and the shifting balance between the number of healthy young workers paying in, vs. unhealthy or older workers spending out, these problems greatly exacerbate the double-digit inflation that has become a recurring characteristic of health insurance premiums, and threaten the very existence of managed care.

In recent years, health care policy experts have been urging medical institutions to convert their paper records to electronic form as an important step to avoid medication errors and other mistakes caused by incomplete patient information. Electronic systems also facilitate evaluation of individual physicians and the effectiveness of new treatments. Given the technology's enormous cost, coupled with the difficulty of persuading busy physicians to change the way they practice, as well as the privacy concerns, adoption has been slowed.

The goal of Care Focused Purchasing is to create a scorecard of providers and physicians enabling health care consumers to make better decisions. The employer group is united around the belief that current health plan designs and cost-sharing strategies are short-sighted. They are looking for additional companies to join this organization.

Contributing to competition among insurers is the decline in the number of jobs in manufacturing and other fields that traditionally offered generous employer health plans. New jobs tend to be in small businesses and service industries that are likely to offer more austere benefits, if any. This scenario suggests that insurers are more likely to be competing for customers and competing on the basis of price.

Several insurers are engaged in price competition, placing downward pressure on policy costs. But overall, insurers are still careful about their underwriting and pricing.

Today's health care market must balance the demands of many stakeholders. Consumers want choice over providers, benefit flexibility, and freedom from having to obtain permission for health services. At the same time, employer groups demand that plans hold the line on premiums, or pass cost-increases along to employees. Provider organizations, caught in the middle of these conflicting interests--containing costs yet providing unfettered access to care--are struggling to balance their own capital, financial risk, and service levels.

While many people may use the Internet to research buying a new car or planning a vacation, they may be less likely to use it for obtaining information on a medical condition. Those who do use the Internet to gather health information are more likely to be white, well-educated, and higher-paid.