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A framework for evaluating underutilization of health care services

AMERICAN JOURNAL OF MEDICAL QUALITY 1999年第2期14卷 89-97页

作者： Fetterolf, DE Highmark Inc Pittsburgh PA 15222 USA

Underutilization is becoming increasingly recognized as an area of importance in managed care, where aggressive measures to control overutilization are creating concern among the general public. The author sought solid definition of underutilization and methods for its evaluation in the medical literature but was impressed at the small number of peer reviewed articles on the subject. A review of key issues is discussed, including a number of methods a health plan may use to approach the identification of underutilization within its domain. Methods include the use of "gold standard" population health requirements;statistically defined underutilization;second-order, combined variables;and socially defined underutilization. Sample statistics identified within the author's plan are identified, and recommendations for their implementation and use are made.

关键词：坚持准则卫生服务易得程度卫生服务滥用/统计学和数值数据卫生服务研究/方法管理医疗规划/利用质量指标卫生保健转诊和会诊/统计学和数值数据美国利用情况审核/方法人类

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Provider assessments of the Massachusetts Behavioral Health Program: Year 7

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ADMINISTRATION AND POLICY IN MENTAL HEALTH 2002年第6期29卷 519-524页

作者： Beinecke, RH Vore, N Suffolk Univ Dept Publ Management Boston MA 02108 USA

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Managed care: US research evidence and its lessons for the NHS

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Journal of Health Services Research and Policy 1998年第3期3卷 173-184页

作者： Steiner, A. Robinson, R. Institute for Health Policy Studies University of Southampton Southampton SO17 1BJ 129 University Road United Kingdom

Objectives: To review the high quality US evidence on performance of managed health care organisations and the available US evidence on specific managed care techniques;namely, financial incentives, utilisation management and review, physician profiling and disease management. Methods: Literature searches were conducted using numerous databases including Medline, Embase, the Social Sciences Citation Index and the National Health Service (NHS) Centre for Reviews and Dissemination library. For inclusion of evaluations of overall performance, studies had to use a comparison group (typically fee-for-service patients), make appropriate statistical adjustments for differences between groups, and be published in a peer-reviewed journal from 1980 forward. For assessments of techniques, less-demanding inclusion criteria reflected the paucity of generalisable literature;however, more current results were required (1990 forward). Results: We identified 70 articles for systematic review, covering 18 dimensions of performance (e.g. utilisation, quality of care, consumer satisfaction, equity). The strength of the evidence varied by dimension. It was strongest for utilisation and quality. In general, managed care seems to reduce hospitalisation and use of high-cost discretionary services, to increase preventive screening, and to be neutral in terms of patient outcomes. As for specific techniques, we identified 19 articles for review, but limitations of these studies prevented our drawing any definite conclusions about techniques' effectiveness. This is an important, if somewhat negative, conclusion. Conclusions: Applying US evidence is complicated by an irrelevant comparator and a higher baseline of utilisation. Managed care brought Americans the familiar NHS practices of population-based health care and resource management through gatekeeping;hence, changes due to UK adoption of managed care techniques may be modest. US evidence should be used to generate hypotheses, not to predi

关键词：疾病管理评价研究按诊疗收费计划/组织和管理按诊疗收费计划/标准按诊疗收费计划/利用大不列颠卫生保健公平提供卫生服务研究管理医疗规划/组织和管理管理医疗规划/标准管理医疗规划/利用模型组织管理医师奖励计划医师诊疗模式公费医疗美国利用情况审核人类

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Mental health carve-outs: Effects and implications

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Medical Care Research and Review 1999年第SUPPL. 2期56.0卷 37-59页

作者： Grazier, Kyle L. Eselius, Laura L. University of Michigan Harvard University

To control the rise in expenditures and to increase access to mental health and substance abuse (MH/SA) services, a growing number of employers and states are implementing a 'carve-out.' Under this arrangement, the sponsor separates insurance benefits by disease or condition, service category, or population and contracts separately for the management of care and/or associated risks. A carve-out allows a unique set of managed care techniques to be applied to a subset of particularly costly or complex benefits. This article describes various carve-out models, discusses the potential advantages and disadvantages of a full carve-out, and summarizes recent public and private sector research regarding the strategy's effects on access and use, cost savings and shifting, and quality of care. It concludes by discussing approaches to the assessment and monitoring of the processes and outcomes associated with a MH/SA carve-out.

关键词：合同业务/经济学费用控制疾病管理雇主承担保健费用/发展趋势保健福利计划雇员/经济学卫生服务易得程度管理医疗规划/组织和管理管理医疗规划/利用 Medicaid/经济学精神卫生服务/组织和管理精神卫生服务/利用生产线管理美国人类

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The economic impact of capitated care for high utilizers of public mental health services: The Los Angeles PARTNERS program experience

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JOURNAL OF BEHAVIORAL HEALTH SERVICES & RESEARCH 1999年第4期26卷 416-429页

作者： Kapur, K Young, AS Murata, D Sullivan, G Koegel, P Rand Corp Santa Monica CA 90401 USA Univ Calif Los Angeles Inst Neuropsychiat Dept Psychiat Los Angeles CA 90024 USA W Los Angeles HealthCare Ctr Vet Hlth Adm Los Angeles CA USA Los Angeles Cty Dept Mental Hlth Los Angeles CA USA Vet Integrated Serv Network Vet Hlth Adm N Little Rock AK USA Univ Arkansas Med Sci Little Rock AR 72205 USA

Las Angeles PARTNERS, or "people achieving rehabilitation together need empowering respectful support," is a treatment program that uses capitation to shift risk far treatment costs of high utilizers of public mental health services to private community-based treatment organizations. This analysis reveals two important findings from PARTNERS. First, the economic incentives created by capitation contributed to the disenrollment of PARTNERS clients;furthermore, factors such as not speaking English or Spanish or having schizophrenia increased the probability of disenrollment. Second, analyses of health costs for enrollees in the PARTNERS capitation program suggest that the program did not result in a change in total casts. However the program increased the use of community-based care and increased treatment costs for clients with lower preprogram costs but decreased costs for the clients with high preprogram costs. These results suggest that future capitation programs for this severely ill population would benefit from using detailed clinical information to determine program eligibility and to set risk-adjusted capitation rates.

关键词：按人收费/统计学和数值数据社区精神卫生服务/经济学费用分配管理医疗规划/经济学管理医疗规划/利用精神障碍/经济学精神障碍/流行病学精神障碍/康复精神卫生服务/经济学精神卫生服务/利用私营部门/经济学私营部门/利用公营部门/经济学公营部门/利用危险处理/经济学市区人口人类

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Substance abuse service utilization under managed care: HMOs versus carve-out plans

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JOURNAL OF BEHAVIORAL HEALTH SERVICES & RESEARCH 1999年第4期26卷 451-456页

作者： Stein, B Reardon, E Sturm, R Rand Corp Santa Monica CA 90401 USA

Managed behavioral health care organizations are increasingly managing Americans' substance abuse by using carve-outs, but little information is available about how this has affected service utilization and costs when compared to HMOs. One employer's claims for substance abuse services delivered under a carve-out arrangement are compared to prior HMO claims information. Under the carve-out arrangement, inpatient and outpatient service utilization are found to decrease, but intermediate service utilization dramatically increases. Costs per unit service decrease for all services. The pattern of changes is different from that seen for mental health services, suggesting that different factors may be applicable to substance abuse services.

关键词：行为疗法/经济学费用效益分析健康维护组织/经济学健康维护组织/利用管理医疗规划/经济学管理医疗规划/利用精神卫生服务/经济学精神卫生服务/利用物质相关性障碍/经济学物质相关性障碍/流行病学物质相关性障碍/康复利用情况审核成年人女(雌)性人类男(雄)性中年人

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Revamping health-care benefits to reduce costs and improve competitiveness at DuPont.

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Employment relations today 1996年第1期23卷 69-76页

作者： McNutt, R.P. Wilmington DE United States

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The Massachusetts Behavioral Health Program year 5: Transition to a new managed care organization

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ADMINISTRATION AND POLICY IN MENTAL HEALTH AND MENTAL HEALTH SERVICES RESEARCH 1999年第5期26卷 313-327页

作者： Beinecke, RH Keane, RJ Symanzick, M Casey, D Suffolk Univ Dept Publ Management Boston MA 02108 USA Boston Coll Sch Social Work Chestnut Hill MA 02167 USA

Year 5 of the Massachusetts Behavioral Health Program was a transition to management by a new private managed care organization. Fifty-eight providers interviewed for an ongoing panel survey reported slightly lower levels of quality, access, utilization, and length of stay than a year earlier. Relationships with providers and advocates improved after an initial difficult period, while consumer and family involvement at all levels remained low. The greatest changes in managed care appeared to take place during the initial transition from fee-for-service care, but intractable problems continue, and full participation of stakeholders seems difficult to achieve.

关键词：医务工作者的态度行为医学/组织和管理行为医学/发展趋势用户满意/统计学和数值数据合同业务/组织和管理卫生保健调查卫生服务易得程度/统计学和数值数据管理医疗规划/组织和管理管理医疗规划/标准管理医疗规划/利用马萨诸塞 Medicaid/组织和管理精神障碍/康复规划制订卫生保健质量/统计学和数值数据物质相关性障碍/康复美国人类

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HEDIS measures and managed care enrollment

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MEDICAL CARE RESEARCH AND REVIEW 1999年第2-Sup期56卷 60-84页

作者： Scanlon, DP Chernew, M Penn State Univ University Pk PA 16802 USA Univ Michigan Ann Arbor MI 48109 USA

This article examines the relationship between 1996 health plan enrollment and both HEDIS-based plan performance ratings and individual HEDIS measures. Data were obtained from a large firm that collected, aggregated, and disseminated plan performance ratings to its employees. Plan market share regressions are estimated controlling for out-of-pocket price and model type in addition to the plan ratings and HEDIS measures. The results suggest that employees did not respond strongly to the provided ratings. There are several potential explanations for the lack of response, including difficulty understanding the ratings and never having seen them. In addition, employees may base their plan choices on information that is obtained from their own past experience, friends, family, and colleagues. The pattern of results suggests that such information is important. Counterintuitive signs most likely reflect an inverse correlation between some HEDIS ratings (or measures) and attributes employees observe informally.

关键词：用户满意保健福利计划雇员/经济学保健福利计划雇员/统计学和数值数据信息服务管理医疗规划/经济学管理医疗规划/标准管理医疗规划/利用模型经济计量学卫生保健质量回归分析美国成年人女(雌)性人类男(雄)性中年人

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Identification of significant information sources in a health care coverage decision

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Health Marketing Quarterly 1990年第1-2期8卷 9-16页

作者： Thompson, Ann Marie Rao, C.P. Northern Illinois University DeKalb IL 60115 United States University of Arkansas Fayetteville AR 72701 United States

Using partial correlation analysis, this research identified the significant information sources in a health care coverage decision. The findings were used to make communication suggestions for the marketing of open a... 详细信息

关键词：用户参与/统计学和数值数据决策评价研究管理医疗规划/利用卫生服务使用研究/方法劝导交谈问卷调查美国

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