Behavioral health services: carved out and managed.
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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)
Impact of pharmacist consultations provided to patients with diabetes on healthcare costs in a health maintenance organization.
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We conducted a study to assess the impact on healthcare utilization and costs of pharmacist consultations provided to patients with diabetes. Data for this study were derived from a larger study conducted by Kaiser Permanente and the University of Southern California that evaluated three alternative models of pharmacist consultations (control, state, and Kaiser). Computerized data were available for patient demographic characteristics and healthcare utilization. We used medication data to classify patient cohorts as insulin only or oral antidiabetics +/- insulin. We estimated hospitalization costs based on diagnostic related group and medication costs based on average wholesale price; office visits were estimated at $70 each. In the insulin only cohort, total costs for patients who had their prescriptions filled at a state model pharmacy were 7.8% less than those for patients filling prescriptions at a control model pharmacy (P = 0.008). In the oral +/- insulin cohort, total costs for patients filling new prescriptions at a Kaiser model pharmacy were 21.9% less than those for patients using a control model pharmacy (P = 0.0001). The state model also was negatively correlated (beta coefficient, -0.0997) with total costs (P = 0.0001). These data suggest that pharmacist consultations provided to patients with diabetes can decrease total healthcare costs in a health maintenance organization. (+info)
Formulary limitations and the elderly: results from the Managed Care Outcomes Project.
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OBJECTIVE: To examine whether restrictive formularies are associated with differences in healthcare resource utilization, including number of office visits, prescriptions, and hospitalizations, and whether this association varies by age. STUDY DESIGN: Cross-sectional, longitudinal study. PATIENTS AND METHODS: Patients enrolled in one of six health maintenance organizations in six different states, three in the eastern and three in the western United States, were eligible for the study. Data from between 1309 and 3938 patients were available for analysis for each of the five diseases studied, for a total of 12,997 patients across all study diseases. Healthcare utilization by patients in the study included more than 99,000 office visits, 1000 hospitalizations, and 240,000 prescriptions. We used severity-adjusted prescription counts, prescription costs, office visit counts, and measures of inpatient hospital utilization to assess the effects of formulary limitations. RESULTS: We found positive, significant associations between the independent variable formulary limitations in drug class and the dependent variables measuring resource utilization. These associations were sometimes significantly greater for elderly patients after controlling for severity of illness and other variables. CONCLUSIONS: Common strategies for decreasing drug expenditures may be associated with higher severity-adjusted resource utilization. In specific areas, this association is more pronounced in the elderly. (+info)
Identification and assessment of high-risk seniors. HMO Workgroup on Care Management.
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CONTEXT: Many older adults with chronic illnesses and multidimensional needs are at high risk of adverse health outcomes, poor quality of life, and heavy use of health-related services. Modern proactive care of older populations includes identification of such high-risk individuals, assessment of their health-related needs, and interventions designed both to meet those needs and to prevent undesirable outcomes. OBJECTIVE: This paper outlines an approach to the tasks of identifying and assessing high-risk seniors. Intervention identification of high-risk seniors (also called case finding) is accomplished through a combination of periodic screening, recognition of high-risk seniors by clinicians, and analysis of administrative databases. Once identified, potentially high-risk individuals undergo on initial assessment in eight domains: cognition, medical conditions, medications, access to care, functional status, social situation, nutrition, and emotional status. The initial assessment is accomplished in a 30- to 45-minute interview conducted by a skilled professional--usually one with a background in nursing. The data are used to link some high-risk persons with appropriate services and to identify others who require more detailed assessments. Detailed assessment is often performed by interdisciplinary teams of various compositions and methods of operation, depending on local circumstances. CONCLUSION: The rapid growth in Medicare managed care is presenting many opportunities for developing more effective strategies for the proactive care for older populations. Identification and assessment of high-risk individuals are important initial steps in this process, paving the way for testing of interventions designed to reduce adverse health consequences and to improve the quality of life. (+info)
Demographics and cost of epilepsy. Based on a presentation by John F. Annegers, PhD.
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Over the past decade, there has been considerable interest in cost-of-illness studies for many diseases, including epilepsy. However, the nature of epilepsy and the wide spectrum of its clinical course make it difficult to assess the overall costs of the disease. Differences in incidence rates by age, gender, etiology, and other demographic variables further complicate the task of assessing costs. The incidence is highest in the first decade of life and in the elderly. A cost-simulation study based on incidence and prognosis sheds light on how costs are estimated. This type of study also serves as a prelude to cost-of-disease studies, cost-benefit studies, and cost-effectiveness studies. Approximately 70% of patients with new-onset epilepsy will achieve remission relatively quickly and at relatively low cost. The picture is far less rosy for patients with intractable seizures; for them, the outcome is fair to poor, and the lifetime costs are high. An empiric version of the cost-stimulation study is now under way. Its objectives are to identify incidence cases of epilepsy in two cohorts, collect longitudinal data on each case, estimate the costs of care over time and across service, measure patterns of resource use over time, and use the resultant direct cost estimates as a national cost model. (+info)
Anticonvulsants: choices and costs. Based on a presentation by Nina Graves, PharmD, FCCP.
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Epilepsy is not a single disease but a constellation of different syndromes and different seizure types. Consequently, establishing a diagnosis on which to base therapy can be complicated. The most commonly used antiepileptic drugs (AEDs) fall into two broad categories: the older AEDs introduced between 1912 and 1973 and the newer AEDs introduced since 1993. The older AEDs have many off-label uses, whereas the newer AEDs, with the exception of gabapentin and lamotrigine, are used exclusively for the treatment of epilepsy. All AEDs are associated to varying degrees with adverse effects on the central nervous system, gastrointestinal tract, blood, liver, and skin. The older AEDs are less expensive than the newer AEDs, but because the newer agents are available in both titration and maintenance-dose strengths, cost savings are possible. Use of the high-strength dose of a newer AED represents a huge cost saving per day compared with using the low-strength dose. Further savings can be realized in the managed care arena if pharmacists are involved in getting patients onto high-strength tablets as quickly as possible. (+info)
Successful implementation of a comprehensive computer-based patient record system in Kaiser Permanente Northwest: strategy and experience.
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Kaiser Permanente Northwest (KPNW) has implemented a computer-based patient record (CPR) system for outpatients. Clinicians at KPNW use this comprehensive CPR to electronically document patient encounters; code diagnoses and procedures; maintain problem lists; order laboratory tests, radiology tests, and prescriptions; and send patient-specific messages and referrals to other medical providers. More than 700 clinicians, representing more than 20 medical and surgical specialties, and 2600 support staff in 31 geographically separate sites use this system as the information foundation of delivery and documentation of health care for KPNW's membership of 430,000. As of May 1998, more than four million visits and two million telephone calls had been processed and documented into the system. More than 5000 outpatient visits are processed and documented each weekday. From an integrated clinical workstation, clinicians also access e-mail, an extensive results-reporting system, and sites on both the internet and KPNW's intranet. This article describes a strategy for and experience with the implementation of a large-scale, comprehensive CPR in an integrated HMO. This information may be useful for persons attempting to implement CPRs in their own institutions. (+info)
Population health management with computerized patient records.
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CIGNA Healthcare of Arizona is using a computerized patient record system (EpicCare) for all medical care delivery at two primary care clinics. Use of this technology to improve quality of care for healthy populations and targeted groups of at-risk persons has led to population health management. This paper discusses strategies used in these endeavors. (+info)