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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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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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How expensive are unlimited substance abuse benefits under managed care?

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JOURNAL OF BEHAVIORAL HEALTH SERVICES & RESEARCH 1999年第2期26卷 203-210页

作者： Sturm, R Zhang, WY Schoenbaum, M Rand Corp Santa Monica CA 90406 USA

Substance abuse (SA) care has been excluded from recent federal and state legislation mandating equal benefits for mental health and medical care ("parity"), largely because of cost concerns. This article studies how many patients are affected by SA coverage limits and the likely implications of limits on insurance payments, using 1996-97 claims from 25 managed care plans with unlimited SA benefits. Changing even stringent limits on annual SA benefits has a small absolute effect on overall insurance costs under managed care, evert though a large percentage of SA patients are affected. Removing an annual limit of $10,000 per year on SA care is estimated to increase insurance payments by about 6 cents per member per year, removing a limit of $1,000 increases payments by about $3.40. As long as care is comprehensively managed, "parity" for SA in employer-sponsored health plans is nor very costly.

关键词：置信区间费用控制保健福利计划雇员/经济学管理医疗规划/经济学管理医疗规划/标准管理医疗规划/利用精神卫生服务/经济学物质相关性障碍/经济学美国人类

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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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Preparing rural communities for managed care: Lessons learned

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JOURNAL OF RURAL HEALTH 1999年第1期15卷 78-86页

作者： Fasciano, NJ Felt-Lisk, S Ricketts, TC Popkin, B Math Policy Res Inc Washington DC 20024 USA

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Substitution of psychiatric care by primary care physicians: Impact of the Iowa Medicaid managed mental health care plan

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ADMINISTRATION AND POLICY IN MENTAL HEALTH 1999年第5期26卷 369-371页

作者： Rohland, BM Rohrer, JE Culica, D Univ Iowa Coll Med Dept Prevent Med Div Hlth Management & Policy Iowa City IA 52242 USA

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THE IMPACT OF PREADMISSION APPROVAL AND CONTINUED STAY REVIEW ON HOSPITAL STAY AND OUTCOME AMONG CHILDREN AND ADOLESCENTS

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JOURNAL OF MENTAL HEALTH ADMINISTRATION 1995年第3期22卷 270-277页

作者： EISEN, SV GRIFFIN, M SEDERER, LI DICKEY, B MIRIN, SM BOSTON UNIV BOSTONMA 02215 HARVARD UNIV SCH MEDDEPT PSYCHIATBOSTONMA 02115

Managed care has emerged as the centerpiece of the health care industry's efforts to control costs and ensure appropriate use of hospital services. This study assesses the impact of managed care by preadmission approval and/or continued stay review on length of psychiatric hospitalization and clinical outcome of children and adolescents. The sample included 277 cases hospitalized in nine psychiatric specialty hospitals in 1990. Demographic and clinical characteristics, hospital ownership type, and preadmission approval or continued stay review were used as independent variables in a multiple regression model to predict length of stay and clinical outcome. Results indicate that the model accounted for 27% of the variance in length of stay. Previous psychiatric hospitalization and for-profit hospital status predicted longer hospitalization. Clinical outcome was not significantly predicted by the model. Managed care did not predict either length of stay or clinical outcome. Implications for health care reform are discussed.

关键词：住院期间审核卫生服务研究医院精神病/利用住院时间管理医疗规划/标准管理医疗规划/利用马萨诸塞组织方针结果评价(卫生保健) 病人入院回归分析青少年儿童女(雌)性人类男(雄)性

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