Managed care quarterly最新文献

Rising employer healthcare costs are driving the need for new cost-saving benefit programs. Consumer-driven health plans have the potential to create savings for employers and better care options for patients. Furthermore, three fundamental forces need to come together for these health plans to become a reality. First, employees need to view healthcare benefits as assets and be provided with the tools to manage those assets. Second, employees must have continuity in the management of their healthcare assets, which includes their medical utilization history. Finally, any savings accumulated in these plans must be employee owned and portable from job to job or available for retirement healthcare needs. Making consumers active participants in the next generation of health plans is a necessity. Making it happen, however, will be a challenge.

Many insurers in non-US markets are experiencing difficulties in developing managed care strategies to combat increasing medical costs. Some attempts to transport managed care techniques outside of the US have failed. Although it is difficult to determine the exact causes of failure, some common threads exist. When these common characteristics are explored, fundamental building blocks will emerge. When introduced, these fundamentals can lead to increased efficiency, thereby paving the way to successful managed care development in non-US markets.

URAC recently completed a study funded by the Robert Wood Johnson Foundation to assess patient safety systems. URAC collected information from 31 separate UM companies. URAC also reviewed software capabilities from four commercial utilization management software vendors. This article describes how utilization management organizations use information technology and UM processes to systematically identify and manage potential patient safety problems. The study also identified research needs to promote future utilization management involvement in patient safety.

The recent innovations in electronic technology, discoveries in biotechnology research and changes in FDA policy have resulted in the fast-growing market of specialty pharmaceuticals. These drug agents offer treatment (where there was often none) for patients with rare, chronic diseases such as pulmonary hypertension, Gaucher disease, hemophilia and others. The new drug therapies are expensive, with an annual average cost of $71,000 a year, and often require specialized handling and administration. In response to market need, a new service sector called specialty pharmacy has emerged to manage these therapies. The specialty pharmacy provides services for specialized drug delivery and handling, patient education, drug administration, treatment oversight, and reimbursement assistance. These services assist healthcare providers and payors to enhance quality care and reduce the administrative burden of managing treatments for patients with rare disease.

Many complex issues are associated with specialty pharmaceuticals in the development of a successful specialty pharmaceutical program. A previous article focused on the definition and scope of specialty pharmaceuticals. This article explores the mechanics of developing and managing a specialty pharmaceutical program, specifically, authorization management.

This article examines the national standards for safeguarding the confidentiality, integrity, and availability of electronic protected health information under the final Privacy Rule of the Health Insurance Portability and Accountability Act (HIPAA). The standards require entities covered by the rule to implement basic safeguards to protect electronic protected health information from unauthorized access, alteration, deletion, and transmission. The final privacy rule applies to protected health information in any form.

Specialized managed care programs such as the MnDHO program can improve the health care experience for people with disabilities if they include seamless care coordination among disability competent providers and promote consumer participation. Findings indicate greater satisfaction with care coordination, consumer participation, and provider knowledge in the AXIS/UCare complete program.

Individual patient responses to some of the standard-of-care treatments for post operative pain management are unpredictable, but studies have shown undertreatment of acute post operative pain is common. There are new, innovative techniques for postoperative pain management that may improve a patients' recovery period. These techniques are also economically beneficial, and may contribute to the reduction of long-term care costs. Overall, the less time a patient is removed from normal day-to-day activity, the more satisfied they tend to be with their surgical experience. The following article addresses these and other issues surrounding the reduction of pain and cost after surgery.