Historically, employers have asked health plans to measure performance in terms of quality, utilization, satisfaction, and cost. As organizations collected these data, employers realized that rarely were all the data ...
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Historically, employers have asked health plans to measure performance in terms of quality, utilization, satisfaction, and cost. As organizations collected these data, employers realized that rarely were all the data comparable. Several employers, such as Xerox Corporation, Digital Equipment Corporation, and Bull HN Information Systems, Inc., agreed to work together to create reporting criteria that would standardize measurement. This collaboration resulted in the Health Plan Employer Data Information Set (HEDIS) criteria. This article reviews some of the implementation issues and decisions that a plan must resolve to gather accurate HEDIS data.
It is estimated that 50% of all practicing psychiatrists have at least one contract with a managed care organization (AMA, 1994). As the field of psychiatry increasingly adopts the tools of managed care, it is importa...
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It is estimated that 50% of all practicing psychiatrists have at least one contract with a managed care organization (AMA, 1994). As the field of psychiatry increasingly adopts the tools of managed care, it is important for researchers to clarify the extent to which managed care affects the practice of psychiatry, and how the changing practice climate in turn affects patients seeking mental health care. A diverse array of managed care techniques have been introduced into the profession of psychiatry in an effort to alter treatment patterns. One commonly used tool, utilization review, can alter treatment patterns by restricting access to treatment alternatives and providing incentives to practitioners to meet managed care goals. Other managed care tools are the determination of "medical necessity" and the use of triage and treatment guidelines among insured enrollees requesting services. These guidelines serve as selection criteria to help determine not only which members of the insured population receive treatment for mental health care, but also to determine the allocation of enrollees to staff members and to prescribe the starting point for the types of services received. Managed care psychiatrists may find changes not only in their client populations and treatment alternatives, but in many other aspects of their practice. Some psychiatrists working in managed care have become increasingly involved in treatment teams. Other psychiatrists contracting with MCOs are reserved for medication management, consultation, or administration in carved-out mental health departments or agencies. Little is known about the extent to which managed care restrictions affect psychiatrists' patient care roles, collaborative relationships with other mental health professionals, and the degree to which psychiatrists are involved in administration of managed mental health care benefits. The era of managed care has constrained the clinical decision making of psychiatrists whose magnitude
Healthcare organizations throughout the United States are attempting to find solutions to spiraling healthcare costs. Hospital administrators are questioning the cost-effectiveness of their care delivery models, while...
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Healthcare organizations throughout the United States are attempting to find solutions to spiraling healthcare costs. Hospital administrators are questioning the cost-effectiveness of their care delivery models, while healthcare professionals are developing innovative measures to increase the cost-effective use of resources. This article explores hospital-based case management measures that are being used not only to control costs but also to de-escalate the continuously accelerating cost increases.
The Carrier Foundation, a not-for-profit psychiatric facility in Belle Mead, NJ, has been working with managed care for the past 5 years. As managed care began to affect patients' access to care, the quality impro...
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The Carrier Foundation, a not-for-profit psychiatric facility in Belle Mead, NJ, has been working with managed care for the past 5 years. As managed care began to affect patients' access to care, the quality improvement department at The Carrier Foundation became involved in case management. Through case management, the quality improvement department began to provide guidance to private review organizations to preserve and protect patients' rights and to ensure accurate reporting of clinical data.
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