Organization and financing of British primary care groups and trusts: observations through the prism of US managed care

2002 ◽  
Vol 7 (1) ◽  
pp. 43-50 ◽  
Author(s):  
Jonathan Weiner ◽  
Steve Gillam ◽  
Richard Lewis
Keyword(s):  
Primary Care ◽  
Managed Care ◽  
Health Maintenance Organizations ◽  
Health Maintenance ◽  
American Experience ◽  
Care Groups ◽  
Integrated Delivery Systems ◽  
The Usa ◽  
Integrated Delivery ◽  
Managed Care Organizations

There are many parallels between the UK's new primary care commissioning organizations and the managed care organizations and integrated delivery systems that have evolved in the USA over the last three decades. Those building primary care groups and trusts (PCG/Ts) can learn from the American experience with health maintenance organizations and other similar entities. These lessons should also be relevant to those in other countries interested in establishing innovative primary care led organizations within the broader structure of a socialized health care system. Following an overview of US managed care and an update of the progress of the UK's PCG/Ts, we go on to suggest how new consortia of PCG/Ts might be developed and how budgets and provider incentives could be structured. This international comparison suggests that the resources needed to support the development of effective PCG/Ts will be considerable, as will the need to maintain organizational flexibility. If primary care organizations are to thrive, it will be essential to develop truly integrated budgets for primary and secondary care.

Managing Care and the Risk for Managing Quality

1992 ◽  
Vol 7 (1) ◽  
pp. 12-22
Author(s):  
Daniel M. Mulholland
Keyword(s):  
Managed Care ◽  
Health Maintenance Organizations ◽  
Health Maintenance ◽  
Managed Care Organizations

The purpose of this paper is to outline the potential liability of managed care organizations. Specifically, the paper enumerates the various types of liability of health maintenance organizations for the negligent acts of its contracting physicians. The recent cases discussed below demonstrate both the extent to which courts are willing to stretch the liability of HMOs and also the limits that courts place on that liability.

Procedural Protections for Patients in Capitated Health Plans

1996 ◽  
Vol 22 (2-3) ◽  
pp. 301-330
Author(s):  
Eleanor D. Kinney
Keyword(s):  
Health Care ◽  
Health Care Professionals ◽  
Health Care Services ◽  
Health Maintenance Organizations ◽  
Data Systems ◽  
American Health Care System ◽  
Health Maintenance ◽  
Integrated Delivery ◽  
Provider Organization ◽  
Delivery Networks

In the American health care system, payers are rapidly moving toward the use of capitation as the preferred method for paying for health care services for sponsored patients. n capitation, the payer pays a provider organization a set rate per patient to care for a group of patients. The provider organization assumes the risk of the actual costs of caring for these covered lives. The theory of capitation is that providers, by assuming risk, will have incentives to contain their costs.The provider entity that provides the care can take many corporate forms. A capitated provider can be a small group of physicians with admitting privileges at a single hospital or a complex integrated delivery network comprised of hospitals, physicians, and other health care professionals and institutions with integrated case management and data systems. Currently such integrated delivery networks assume a variety of organizational forms, ranging from traditional staff model health maintenance organizations (HMOs) in which physicians are employees of the health plan to physician hospital organizations (PHOs) in which physicians and hospitals join together for purposes of contracting with payers. Hospitals and physicians belonging to their medical staffs are motivated to form integrated delivery networks or other consolidated business organizations in order to contract with payers that seek providers willing to accept financial risk for the care of sponsored patients. Providers join such arrangements out of fear of losing patients if they do not.

Adherence to standards of care by health maintenance organizations in Israel and the USA

2010 ◽  
Vol 23 (1) ◽  
pp. 15-25 ◽  
Author(s):  
B. Rosen ◽  
A. Porath ◽  
L. G. Pawlson ◽  
M. R. Chassin ◽  
J. Benbassat
Keyword(s):  
Health Maintenance Organizations ◽  
Standards Of Care ◽  
Health Maintenance ◽  
The Usa

Ethics Case Consultation in Primary Care: Contextual Challenges for Clinical Ethicists

2009 ◽  
Vol 18 (4) ◽  
pp. 397-405 ◽  
Author(s):  
ANNE SLOWTHER
Keyword(s):  
Primary Care ◽  
Clinical Ethics ◽  
Western Europe ◽  
Ethics Consultation ◽  
Ethics Committees ◽  
The United States ◽  
Health Maintenance Organizations ◽  
Ethics Committee ◽  
Health Maintenance ◽  
Case Consultation

The development of ethics case consultation over the past 30 years, initially in North America and recently in Western Europe, has primarily taken place in the secondary or tertiary healthcare settings. The predominant model for ethics consultation, in some countries overwhelmingly so, is a hospital-based clinical ethics committee. In the United States, accreditation boards suggest the ethics committee model as a way of meeting the ethics component of the accreditation requirement for payment by Health Maintenance Organizations (HMOs), and in some European countries, there are legislatory requirements or government recommendations for hospitals to have clinical ethics committees. There is no corresponding pressure for primary care services to have ethics committees or ethics consultants to advise clinicians, patients, and families on the difficult ethical decisions that arise in clinical practice.

"DR UNNECESSARY"

PEDIATRICS ◽  
1996 ◽  
Vol 97 (2) ◽  
pp. A30-A30
Author(s):  
J. F. L.
Keyword(s):  
Managed Care ◽  
Private Practice ◽  
Psychiatric Treatment ◽  
Health Maintenance Organizations ◽  
Case Managers ◽  
Fee For Service ◽  
Health Maintenance ◽  
Insurance Costs ◽  
Treatment Plans

The old reality for many psychiatrists was a private practice filled with long-term patients who paid $100 or more for 50 minutes of talk. The new reality? Managing medication for up to 30 new patients a week for half the hourly fee—and answering to case managers who aren't even doctors. No wonder the number of U.S. medical school graduates in psychiatric residencies dropped nearly 12%—to 3909 from 4447—between 1988 and 1994. The blame—or the credit—goes to managed care, the catchall term for the revolution that has swept through both the medical and mental health care fields in recent years. Desperate to cut runaway health insurance costs, most companies have axed longstanding fee-for-service plans and instead steer employees seeking psychiatric treatment to health maintenance organizations or specialized managed-care firms. These organizations decide the type and amount of care patients receive. Psychiatrists have to get with the program—and agree to its treatment plans and fee schedules—or watch the bulk of their practices disappear. Only the rare psychiatrist can attract private patients wealthy enough to pay for traditional psychotherapy without the benefit of insurance.

Tort Liability for Managed Care: The Weakening of ERISA's Protective Shield

1997 ◽  
Vol 25 (2-3) ◽  
pp. 160-179 ◽  
Author(s):  
Karen A. Jordan
Keyword(s):  
Managed Care ◽  
Health Maintenance Organizations ◽  
Tort Liability ◽  
Health Maintenance ◽  
Vicarious Liability ◽  
Care Plans ◽  
Protective Shield ◽  
Negligent Treatment ◽  
The Cost ◽  
Liability Claims

The risk of tort liability for health maintenance organizations (HMOs) and other managed care plans has dramatically increased in recent years. This is due in part to the growing percentage of health care rendered through managed care plans. The cost-containment mechanisms commonly used by managed care plans, such as limiting access to services and/or choice of providers, creates a climate ripe for disputes that may end up in court. As dissatisfied patients and providers seek recourse in the courts, tort doctrines are extended and new legal theories emerge as needed. For example, the concepts of direct and vicarious tort liability developed in the hospital context have been extended by courts to encompass HMOs. vicarious liability claims, based on ostensible agency or respondeat superior doctrines, have been brought against HMOs and managed care plans for negligent treatment by physicians selected to provide care to members.

A Deliberative Model of Corporate Medical Management

2000 ◽  
Vol 28 (2) ◽  
pp. 125-136
Author(s):  
Mark E. Meaney
Keyword(s):  
Managed Care ◽  
Care Delivery ◽  
Cost Savings ◽  
Health Maintenance Organizations ◽  
Health Care Delivery System ◽  
Healthcare Management ◽  
Management Tool ◽  
Ethical Challenges ◽  
Health Maintenance ◽  
Real Cost

Managed care is evolving in ways that pose unique ethical challenges to those interested in the intersection of clinical and organizational ethics. For example, Disease Management (DM) is a form of managed care that has emerged in response to chronic illness. DM is a healthcare management tool that coordinates resources across an entire health care delivery system and throughout the life cycle of chronic disease. Health Maintenance Organizations have reduced some costs in the delivery of acute care, but real cost savings will result only with greater efficiencies in the delivery of costly chronic care. DM is a systematic, population-based approach that identifies persons at risk of chronic ailment, intervenes with specific programs of care, measures clinical and other outcomes, and provides continuous quality improvement. Characterized as a movement to patient-driven services, DM involves a complex web of provider relations.

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