Managed care quarterly最新文献

At a time when many managed care organizations (MCOs) have announced improvements in administrative systems and a desire to ease provider relations and pay providers correctly and timely, many physician organizations continue to experience great difficulty in obtaining prompt and accurate claims payment. To understand this phenomenon better, physician organizations at two leading academic medical centers in the Northeast and South, respectively, compiled an analysis of their recent managed care claims payment experience. This analysis revealed substantial underpayments from MCOs, and documented the added administrative expense required to recover such underpayments.

These new "health plans" are personalized, consumer-specific action plans created partially by and individually for consumers. They are aimed at improving consumers' overall health, reducing their risks for expensive and life-diminishing diseases, improving their self-management of chronic conditions they already have, and generally improving their quality of life, insofar as broadly defined "health improvement" will achieve that. This new form of "health plan" has been adopted by one of the major proponents of prospective health, Duke University Health System in Durham, NC.

Future research needs to clarify the biases in clinical practice and potential barriers that may exist at both the provider and health plan levels that exclude men with physical disabilities from routine preventive services. As the population of people with disabilities ages and lives longer, it is necessary that routine preventive services are accessible and made available to them, regardless of gender, disability, or health insurance type.

A growing number of states are enrolling Medicaid beneficiaries with disabilities into prepaid health plans. This shift from fee-for-service insurance to pre-paid insurance typically transfers the risk from the state to the health plans. However, health plans want the state Medicaid program to minimize their financial risk. Interviews with Medicaid officials in six states provided insights into how each state selected its financial risk reduction method. Officials also offered advice for other states. Widespread recommendations included allowing ample time for discussions with disability advocacy groups and health plans, allowing two years for financial modeling and start up, and selecting a method that is politically acceptable, financially feasible, and actuarially sound. The primary impediment to diagnostic-based payments is lack of data.

The MedicareChoice program was created to expand choice and encourage beneficiaries to more actively consider the choices they have. This article assesses how "salient" choice is to Medicare beneficiaries. More than half of all Medicare beneficiaries in 2000 reported that they either have never considered their options to join a Medicare HMO or get supplemental coverage (44 percent) or did so last when they first became Medicare eligible (14 percent). Overall, 14 percent of Medicare beneficiaries found choice salient in 2000. Those new to Medicare or forced to switch because their plan left the program were more likely to consider choice, as expected. The multi-variate analysis shows that existing HMO enrollment is most strongly associated with salience of choice and also that this effect operates especially in the individual market. The findings of this research are consistent with the literature in highlighting the limited salience of choice to Medicare beneficiaries and the even more limited extent of actual switching that occurs in that market. There is little reason to believe that choice is more salient now than when the study was done. Policymakers who seek to encourage market-based solutions confront a dilemma: How to create incentives for a choice that most beneficiaries do not find particularly salient.