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Results of provider self-adjudication using the prudent layperson standard compared with the managed care organization's emergency department claim review process

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ANNALS OF EMERGENCY MEDICINE 2000年第3期36卷 212-218页

作者： Shesser, R Holtermann, K Smith, J Braun, J George Washington Univ Dept Emergency Med Washington DC 20037 USA

Study objectives: We compare the results of a provider "self-adjudicating" outpatient emergency department claims using a "presenting symptom-based" system with the managed care organization (MCO) adjudicating the claims using a "final diagnosis-based" system. Methods: All outpatient visits from one MCO to an urban, university hospital between January 1, 1998, and February 28, 1999, were included. Each record was reviewed by 2 methods to determine whether the visit qualified for payment under the MCO's benefit structure. Under the provider adjudication, symptom-based system, all visits with nursing triage levels of immediate/emergency were approved automatically. Those with triage levels of delayed/nonurgent were reviewed by an emergency physician and approved if, in the physician's opinion, the presenting symptoms met the emergency criteria under the District of Columbia's Access to Emergency Services Act. A second claims review, blinded to the first, was performed with the diagnosis-based system used by the MCO before approval of the prudent layperson standard. This review divided the records into "approve," "deny," and "suspend" categories according to the discharge International Classification of Diseases, ninth revision code. The results of the 2 reviews were compared. Results: We reviewed 1,830 records;836 (46%) cases were triaged as immediate/emergency and 994 (54%) as delayed/nonurgent. Of the 994 delayed/nonurgent visits, physician review determined that 607 (61%) met the prudent layperson standard and 387 (39%) did not. Overall, the provider self-adjudication system determined that 1,443 (78.8%) of the 1,830 visits should be approved for insurance coverage. The MCO's system approved 966 (53%), denied 335 (18%), and suspended 529 (29%). Provider self-adjudication using a symptom-based system resulted in the immediate approval of 1,443 (77.8%) visits compared with 966 (52.7%) by a diagnosis-based system (P<.001). Excluding the 529 suspended claims, McNemar's

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Effect of medicaid managed care on pregnancy complications

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OBSTETRICS AND GYNECOLOGY 2000年第1期95卷 6-13页

作者： Oleske, DM Linn, ES Nachman, KL Marder, RJ Sangl, JA Smith, T Rush Univ Dept Hlth Syst Management Chicago IL 60612 USA Advocate Lutheran Hosp Pk Ridge IL USA Agcy Hlth Care Policy & Res Rockville MD USA Calif Dept Hlth Serv Maternal & Child Hlth Branch Sacramento CA USA

Objective: This study examined the impact of managed care on hospital obstetric outcomes in Medicaid-sponsored women. Methods: The study sample consisted of a total of 525,517 maternal deliveries for singleton births from three payer groups, Medicaid managed care, Medicaid fee-for-service, and private managed care in 439 short-term-stay nonfederal hospitals in California and Florida. Quality of care comparisons were made using six indicators. Data were derived from linked computer files of birth certificates, hospital discharge abstracts, Medicaid eligibility records, Medicaid health care claims, and surveys of hospital characteristics. Results: The overall multivariate likelihood of an adverse maternal outcome during hospitalization for a delivery was not significantly different between Medicaid managed care and Medicaid fee-for-service groups in California and Florida. However, mothers in the Medicaid managed care group compared with mothers in the private managed care group experienced a higher likelihood of eclampsia (California) (adjusted odds ratio = 1.26;95% confidence interval 1.05, 1.57;P=.04). Conclusion: Overall, managed care has not adversely affected pregnancy outcomes in Medicaid-sponsored women. Yet, payer system changes may be insufficient to achieve complete parity of outcomes relative to private managed care patients. (Obstet Gynecol 2000;95:6-13. (C) 2000 by The American College of Obstetricians and Gynecologists.).

关键词：加利福尼亚/流行病学按诊疗收费计划佛罗里达/流行病学 Logistic模型管理医疗规划/统计学和数值数据 Medicaid/组织和管理妊娠并发症/经济学妊娠并发症/流行病学妊娠结局/经济学妊娠结局/流行病学质量保证卫生保健美国女(雌)性人类妊娠

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Race and differences in breast cancer survival in a managed care population

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JOURNAL OF THE NATIONAL CANCER INSTITUTE 1999年第17期91卷 1487-1491页

作者： Yood, MU Johnson, CC Blount, A Abrams, J Wolman, E McCarthy, BD Raju, U Nathanson, DS Worsham, M Wolman, SR Henry Ford Hlth Sci Ctr Josephine Ford Canc Ctr Detroit MI 48202 USA Henry Ford Hlth Sci Ctr Ctr Clin Effectiveness Detroit MI USA Bristol Myers Squibb Wallingford CT USA Henry Ford Hlth Sci Ctr Dept Biostat & Res Epidemiol Detroit MI 48202 USA Henry Ford Hlth Sci Ctr Dept Pathol Detroit MI 48202 USA Henry Ford Hlth Sci Ctr Dept Surg Detroit MI 48202 USA George Mason Univ Dept Syst Engn & Operat Res Fairfax VA 22030 USA Uniformed Serv Univ Hlth Sci Dept Pathol Bethesda MD 20814 USA

Background African-American women with breast cancer have poorer survival than European-American women. After adjustment for socioeconomic variables, survival differences diminish but do not disappear, possibly because of residual differences in health care access, biology, or behavior. This study compared breast cancer survival in African-American and European-American women with similar health care access. Methods: We measured survival in women with breast cancer who are served by a large medical group and a metropolitan Detroit health maintenance organization where screening, diagnosis, treatment, and follow-up are based on standard practices and mammography is a covered benefit. We abstracted data on African-American and European-American women who had been diagnosed with breast cancer from January 1986 through Apl il 1996 (n = 886) and followed these women for survival through April 1997 (137 deaths). Results: African-American women were diagnosed at a later stage than were European-American women, Median follow-up was 50 months. Five-year survival was 77% for African-American and 84% for European-American women, The crude hazard ratio for African-American women relative to European-American women was 1.6 (95 % confidence interval [CI] = 1.1-2.2), Adjusting only for stage, the hazard ratio was 1.3 (95% CI = 0.9-1.9). Adjusting only for sociodemographic factors (age, marital status, and income), the hazard ratio was 1.2 (95% CI = 0.8-1.9). After adjusting for age, marital status, income, and stage, the hazard ratio was 1.0 (95 % CI = 0.7-1.5), Conclusion: Among women with similar medical care access since before their diagnoses, we found ethnic differences in stage of breast cancer at diagnosis, Adjustment for this difference and for income, age, and marital status resulted in a negligible effect of race on survival.

关键词：非洲裔美国人/统计学和数值数据年龄因素乳腺肿瘤/诊断乳腺肿瘤/人种学乳腺肿瘤/死亡率欧洲大陆世系人群/统计学和数值数据卫生服务易得程度收入管理医疗规划/统计学和数值数据婚姻状况密执安/流行病学比值比存活率城市卫生成年人老年人女(雌)性人类中年人

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Development and implementation of a tobacco consultation program for managed care pharmacists

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AMERICAN JOURNAL OF HEALTH-SYSTEM PHARMACY 2001年第3期58卷 210-+页

作者： Barbour, DM Kaiser Permanente Colorado Clin Pharm Serv Boulder CO 80304 USA

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Re: Race and differences in breast cancer survival in a managed care population

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JOURNAL OF THE NATIONAL CANCER INSTITUTE 2000年第20期92卷 1690-1691页

作者： Dunmore, C Plummer, P Regan, G Mattingly, D Jackson, S Millikan, R Univ N Carolina Dept Epidemiol Lineberger Comprehens Canc Ctr Chapel Hill NC 27599 USA

Yood et al. (1) reported that differences in survival between African-American and white breast cancer patients were negligible after adjustment for age, income, marital status, and stage at diagnosis. The authors studied enrollees in a managed care program where African-American and white women had equal access to health care and similar surgical treatment for breast cancer (2). We determined whether racial differences exist in the surgical treatment for breast cancer within the general population and whether this relationship is altered by adjustment for sociodemographic variables. We used data collected from The Carolina Breast Cancer Study, a population-based case–control study in North Carolina (3). The study was approved by the Institutional Review Board at the University of North Carolina School of Medicine. Multiple logistic regression was used to estimate odds ratios for the type of surgery received: mastectomy (including simple mastectomy, modified radical mastectomy, and total mastectomy) versus breast-conserving surgery (lumpectomy, segmental mastectomy, partial mastectomy, and quandrantectomy). The results of our analysis are presented in Table 1. Taken singly without adjustment for other predictors, the strongest predictors of receiving a mastectomy were later stage at diagnosis (based upon the American Joint Committee on Cancer (AJCC) TNM staging system), lower educational level, lower income, residence in a rural area or small town, and African-American race. After mutual adjustment for all predictors, the strongest predictors were later stage at diagnosis, lower educational level, and residence in a rural area or small town. African-American women were more likely to undergo mastectomy than white women [odds ratio (OR) = 1.5; 95% confidence interval (CI) = 1.1–2.0], but the association disappeared after mutual adjustment for all predictors (OR = 1.1; 95% CI = 0.8–1.7). Our results are similar to those of Muss et al. (4). Muss et al. found that fewer

关键词：非洲裔美国人/统计学和数值数据乳腺肿瘤/死亡率乳腺肿瘤/治疗教育程度欧洲大陆世系人群/统计学和数值数据管理医疗规划/统计学和数值数据乳房切除术/方法危险因素农村人口存活率美国/流行病学女(雌)性人类

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Outcomes improvement: The true mark of quality in managed care

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American Journal of Medical Quality 1999年第5期14卷 202-210页

作者： Armstead, Rodney Leong, Darryl UHP Healthcare Inglewood CA United States Medical Diagnostic Management Inc. Culver City CA United States Medical Diagnostic Management Inc. Culver City CA 90230 300 Corporate Point United States

The definition of the term "quality" continues to be centered on health care providers and not the health of the community. The shift to managed care financing provides a unique opportunity to raise the importance of health outcomes as the true mark of quality in managed care. A widespread fear that managed care organizations are too ready to reduce quality for increased profits has lead to a current national backlash against managed care. Instead of only viewing health plan members as recipients of medical services, health plans should also view members as a population group with subpopulations within them, needing both medical and nonmedical services to improve their health. We introduce the Outcomes Improvement System, an outcomes-driven method for managed care plans and other health systems that incorporates both medical care and population-based health services in a managed care setting.

关键词：卫生服务研究管理医疗规划/标准管理医疗规划/统计学和数值数据管理医疗规划/发展趋势结果评价(卫生保健) 卫生保健质量全面质量管理人类

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Closing the loop: Optimizing physicians' operational and strategic behavior

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ANNALS OF THORACIC SURGERY 1999年第2期68卷 362-366页

作者： Sergeant, PT Blackstone, EH Katholieke Univ Leuven Louvain Belgium Cleveland Clin Fdn Cleveland OH 44195 USA

Clinical databases are essential elements in optimizing medical care. They are no finality by themselves, but essential elements in the generation of knowledge. Optimal medical care starts with optimal care based on existing knowledge. This care continues with the registration of the variability in morbidity, comorbidity, and therapy, but also the registration of the early and late outcome. This should then allow the generation of structured inferences based on this registration and the closure of the loop, by treating patients according to this newly created evidence. (C) 1999 by The Society of Thoracic Surgeons.

关键词：比利时死亡原因冠状动脉分流术/死亡率数据库事实型/统计学和数值数据随访研究医院死亡率管理医疗规划/统计学和数值数据质量保证卫生保健/统计学和数值数据登记/统计学和数值数据存活率分析人类

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Managed care and fee discounts in psychiatry: New evidence

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JOURNAL OF BEHAVIORAL HEALTH SERVICES & RESEARCH 2000年第2期27卷 215-226页

作者： Scheffler, RM Garrett, AB Zarin, DA Pincus, HA Univ Calif Berkeley Sch Publ Hlth Berkeley CA 94720 USA Amer Psychiat Assoc Washington DC 20005 USA Univ Pittsburgh Sch Med Dept Psychiat Pittsburgh PA 15260 USA RAND Corp Santa Monica CA 90406 USA RAND Pittsburgh Hlth Program Pittsburgh PA USA

This article describes the extent of managed care and fee discounting in psychiatric practice using data on 970 randomly sampled American Psychiatric Association members from the 1996 National Survey of Psychiatric Practice. Seventy percent of psychiatrists were found to have some patients in managed behavioral health care programs. The survey data illustrate that psychiatrists' involvement in managed care spans primary practice settings and is fairly evenly distributed across regions of the United States. Nationally, psychiatrists discount fees for 35% of their patients, with significant variation by practice type and extent of involvement in managed behavioral health care. The average level of discount is 25% with little variation by practice type or extent of involvement in managed behavioral health care. There is little evidence that psychiatrists with patients in managed care have higher fee levels than psychiatrists with no patients in managed care.

关键词：费用分担/经济学费用医疗管理医疗规划/经济学管理医疗规划/统计学和数值数据精神卫生服务/经济学人群监测精神病学/经济学精神病学/发展趋势抽样研究美国人类

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Who leaves managed behavioral health care?

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JOURNAL OF BEHAVIORAL HEALTH SERVICES & RESEARCH 1999年第4期26卷 390-399页

作者： Gresenz, CR Sturm, R Rand Corp Santa Monica CA 90401 USA

The growth of managed care and the possibility of biased enrollment and disenrollment rates have raised concerns about cost shifting. This article analyzes the duration of continuous enrollment in a managed behavioral health organization among members with and without behavioral health care utilization and among members with different mental health conditions. Eleven large employers with more than 250,000 members who are enrolled in managed behavioral health plans are studied. Compared to managed care 10 years ago, the rate of disenrollment among patients with depression appears to have dropped. Moreover there appear few differences in disenrollment among users and nonusers of behavioral health services, except for employees for whom coverage is linked to job performance. However patients with substance abuse problems or severe types of disorders are significantly more likely to disenroll than patients with less severe problems.

关键词：行为疗法/经济学行为疗法/统计学和数值数据费用分配保健福利计划雇员/经济学保健福利计划雇员/利用管理医疗规划/经济学管理医疗规划/统计学和数值数据精神障碍/经济学精神障碍/流行病学中止治疗的病人/统计学和数值数据美国青少年成年人老年人人类男(雄)性中年人

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Vulnerable populations and health insurance

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MEDICAL CARE RESEARCH AND REVIEW 2000年第1期57卷 110-134页

作者： Shi, LY Johns Hopkins Univ Sch Publ Hlth & Hyg Dept Hlth Policy & Management Baltimore MD 21205 USA

This study provided a national profile of health insurance of certain vulnerable populations including children, racial/ethnic minorities, low-income families, non-metropolitan statistical area (MSA) residents, and those with poor health status. The study shows an increase in the proportion of uninsured nonelderly population. While public insurance helped reduce the employment- and health-related disparities in private coverage, it has not overcome other disparities related to vulnerable characteristics including race/ethnicity, wages, education, and area of residence. Comparison between health maintenance organization (HMO) and fee-for-service insurance indicates that younger although not much healthier people, racial/ethnic minorities, MSA residents, and those residing in the West and Northeast regions were more likely to have HMO coverage. To reduce significant disparities in health insurance coverage, policy makers will have to consider expanding public insurance coverage, targeting vulnerable groups, partiallarly those with multiple vulnerable characteristics rather than merely the economically distressed. Expecting managed care to achieve cost containment for services provided to vulnerable populations may be unrealistic.

关键词：费用控制按诊疗收费计划/统计学和数值数据卫生服务研究健康状况保险健康/统计学和数值数据 Logistic模型管理医疗规划/统计学和数值数据未参加医疗保险者/统计学和数值数据少数民族/统计学和数值数据模型经济计量学贫困/统计学和数值数据问卷调查美国青少年成年人老年人儿童女(雌)性人类男(雄)性中年人

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