Behavioral health services: carved out and managed.
(17/1777)
This article highlights the financial pressures that led to an examination of how mental healthcare was provided and paid for, and discusses the rise, characteristics, and functioning of carved-out behavioral healthcare. The typical characteristics of managed behavioral health carve outs (MBHCOs), including contracts, payment arrangements, provider networks, and data collection are discussed and illustrated using the example of United Behavioral Health. The article details the function of the MBHCO on cost and utilization, access, quality, and the relationship of behavioral health services to general medical care and other human services, but cautions that further research is needed to evaluate the qualitative aspects of care. (+info)
Cancer carve outs, specialty networks, and disease management: a review of their evolution, effectiveness, and prognosis.
(18/1777)
Specialty care programs for patients with cancer were among the first to be developed, yet they have been some of the slowest to grow or to demonstrate success. This paper reviews the evolution of cancer carve outs, disease management, and specialty networks by distinguishing purchasers from sellers on key attributes. It also describes financing and operational impediments to their growth and summarizes what little published data there is documenting the success of these programs. The paper analyzes the critical factors impeding the development of these cancer programs, and discusses the public policy changes and health services research that will need to be conducted before the performance and market influence of cancer carve outs will reach their full potential. (+info)
Massachusetts Medicaid and the Community Medical Alliance: a new approach to contracting and care delivery for Medicaid-eligible populations with AIDS and severe physical disability.
(19/1777)
This paper discusses the origins and experiences of the Community Medical Alliance (CMA), a Boston-based clinical care system that contracts with the Massachusetts Medicaid program on a fully capitated basis to pay for and deliver a comprehensive set of benefits to individuals with advanced AIDS and individuals with severe disability. Since 1992, the program has enrolled 818 individuals with either severe disability, AIDS, mental retardation, or general SSI-qualifying disability. Under a fee-for-service system, these two groups had received fragmented care. The capitated CMA program emphasizes patient education and self-management strategies, social support and mental health services, and a team approach to healthcare delivery that has reoriented care to primary care physicians, homes, and communities. (+info)
Clinical considerations in GERD (gastroesophageal reflux disease) therapy: focus on cisapride.
(20/1777)
Heartburn, the major symptom of gastrointestinal reflux disease (GERD), is a common condition that is usually self-treated with over-the-counter products. For patients with severe or recurrent symptoms of GERD, pharmacologic therapy includes acid suppression with H2-receptor antagonists and proton pump inhibitors, and, alternatively, the use of prokinetic agents. While all of these are efficacious, given its high efficacy in nonerosive and mild-to-moderate erosive esophagitis, the prokinetic agent cisapride deserves significant consideration in this patient population. (+info)
Heart failure and disease management.
(21/1777)
Disease management is a comprehensive program that identifies a population of patients at risk, provides a coherent framework of coordinated care for these patients, and demonstrates improved outcomes. In applying disease management strategies to heart failure, there is clearly the technology to improve outcomes. The two main issues involved are influencing physician practice patterns and improving patient compliance. A successful disease management program in heart failure should include patient identification patient assessment, patient education and training, patient monitoring, and triage and acute intervention. With the advances in treatment of heart failure, we have the means to keep patients out of the hospital, maintain their functionality, and decrease mortality. The real issue, which is where disease management can help, is how to apply technology in an effective way to turn potential gains into real gains. The key is not to develop more technology, but to implement effectively the technology that exists. (+info)
The economic functions of carve outs in managed care.
(22/1777)
This paper considers the economic functions of contracting separately for a portion of the insurance risk, offering both the payer's (i.e., employer's) and the health plan's perspective. Four major forms of carve outs are discussed: (1) payer specialty carve outs from all health plans; (2) payer specialty carve outs from only indemnity and preferred provider organization arrangements; (3) individual health plan carve outs to specialty vendors; and (4) group practice carve outs to specialty organizations. The paper examines whether carving out care fosters the payer's goal of delivering reasonable healthcare efficiently, how adverse selection affects the provision of healthcare, and the costs of providing this specialized care. (+info)
Carve outs: definition, experience, and choice among candidate conditions.
(23/1777)
Despite increasing discussion of carve outs as a device for controlling costs and improving quality of care, little systematic information exists on the effects of carve outs on cost, quality, and access to healthcare services. In the absence of such information, a conceptual framework is useful for deciding which conditions and populations may benefit from carve-out strategies, and how such arrangements should be designed. After carefully defining carve outs, and distinguishing them from other similar arrangements, this paper identifies five characteristics of a healthcare condition that increase the likelihood that a carve out's benefits will outweigh its drawbacks. The paper also examines the advantages and disadvantages of alternative approaches to structuring and administering carve-out arrangements, including how to pay for services, how to integrate them with mainstream care, provisions for consumer choice and provisions for carve-out accountability. The piece concludes that population carve outs, in which all the healthcare problems of a group of patients are managed by the carve-out organization, have inherent advantages, and identifies candidate conditions for population carve outs. (+info)
Effects of an asthma management program on the asthmatic member: patient-centered results of a 2-year study in a managed care organization.
(24/1777)
OBJECTIVE: To report the results of a 2-year pilot program of asthma education based on National Heart, Lung, and Blood Institute treatment guidelines. PATIENTS AND METHODS: Asthmatic members (n = 6698) of a managed care organization received education about their condition directly or through their primary care physician. Medical and pharmacy administrative claims data were reviewed to measure acute asthma events and prescribed therapies in the first (the baseline) and second years of the study. The claims data were augmented by member surveys from a stratified random sample of 2734 asthmatic patients who were members (6 years of age or older) in the baseline year. RESULTS: Compared with the first year, asthmatic members received fewer inpatient services and the proportion of asthmatic members prescribed oral inhaled corticosteroids increased 30% in the second year. Health-related quality of life, measured with validated general and disease-specific instruments; satisfaction with the quality of care; exposure to patient education; knowledge of the disease; and member's confidence in their ability to manage their disease showed statistically significant improvements during the follow-up year of the program for both adult and child asthmatic members. CONCLUSION: For asthmatic members of this health plan, a comprehensive asthma health management program improved processes of care and outcomes. (+info)