scholarly journals Managed Care and Health Care Expenditures: Evidence from Medicare, 1990-1994

1998 ◽  
Vol 1 (1) ◽  
Author(s):  
Laurence C. Baker ◽  
Sharmila Shankarkumar
Keyword(s):  
Health Care ◽  
Managed Care ◽  
Market Share ◽  
Health Care Policy ◽  
Care Delivery ◽  
Health Care Expenditures ◽  
Spillover Effects ◽  
Fee For Service ◽  
Health Care Market ◽  
Care Activity

Increases in the activity of managed care organizations may have "spillover effects," influencing the entire health care delivery system's performance, so that care for both managed-care and non–managed-care patients is affected. Some proposals for Medicare reform have incorporated spillover effects as a way that increasing Medicare HMO enrollment could contribute to savings for Medicare.This paper investigates the relationship between HMO market share and expenditures for the care of beneficiaries enrolled in traditional fee-for-service Medicare. We find that increases in systemwide HMO market share (which includes both Medicare and non-Medicare enrollment) are associated with declines in both Part A and Part B fee-for-service expenditures. The fact that managed care can influence expenditures for this population, which should be well insulated from the direct effects of managed care, suggests that managed-care activity can have broad effects on the entire health care market. Increases in Medicare HMO market share alone are associated with increases in Part A expenditures and with small decreases in Part B expenditures. This suggests that any spillovers directly associated with Medicare HMO enrollment are small.For general health care policy discussions, these results suggest that assessment of new policies that would influence managed care should account not only for its effects on enrollees but also for its systemwide effects. For Medicare policy discussions, these findings imply that previous results that seemed to show large spillover effects associated with increases in Medicare HMO market share, but inadequately accounted for systemwide managed-care activity and relied on older data, overstated the magnitude of actual Medicare spillovers.

The Managed Health Care Market

1992 ◽  
Vol 5 (2) ◽  
pp. 67-71
Author(s):  
William A. Hemberger
Keyword(s):  
United States ◽  
Health Care ◽  
Managed Care ◽  
Health Care Delivery ◽  
Care Delivery ◽  
The United States ◽  
Health Care Market ◽  
Managed Health Care ◽  
Program Benefit

Health care delivery and benefits in the United States are changing. This article provides a basic description of the present-day components, managed care constructs, and impact of medical/hospital program/ benefit designs on pharmacy programs.

Physician Fees and Managed Care Plans

2002 ◽  
Vol 39 (2) ◽  
pp. 184-193 ◽  
Author(s):  
Jack Zwanziger
Keyword(s):  
Health Care ◽  
Managed Care ◽  
Price Competition ◽  
National Level ◽  
Health Care Expenditures ◽  
Health Care Market ◽  
Physician Services ◽  
Data Set ◽  
Care Plans ◽  
Level Data

One of the objectives of managed care organizations (MCOs) has been to reduce the rate of growth of health care expenditures, including that of physician fees. Yet, due to a lack of data, no one has been able to determine whether MCOs have been successful in encouraging the growth of price competition in the market for physician services in order to slow the growth in physician fees. This study uses a unique, national-level data set to determine what factors influenced the physician fees that MCOs negotiated during the 1990–92 period. The most influential characteristics were physician supply and managed care penetration, which suggest that the introduction of competition into the health care market was an effective force in reducing physician fees.

The Evolution of Physician Credentialing into Managed Care Selective Contracting

1996 ◽  
Vol 22 (2-3) ◽  
pp. 173-203
Author(s):  
John D. Blum
Keyword(s):  
Health Care ◽  
Managed Care ◽  
Care Delivery ◽  
Fee For Service ◽  
Health Delivery ◽  
Payment Incentives ◽  
Legal Perspective ◽  
American Health Care ◽  
Vantage Points ◽  
Hospital Medical Staff

In a field littered with analogies, health care in the mid-nineties is best characterized as an enterprise caught in the violent cross winds of a tropical storm known as managed care. Like a series of hurricanes, managed care has reshaped the landscape of health care delivery in drastic and unpredictable ways. While the forces of managed care have increasingly altered more health care markets, others are only beginning to feel the winds of change. As managed care overtakes fee-for-service (FFS) medicine, profound alterations in health delivery are occurring which affect every aspect of American health care.Particularly noteworthy is the use of capitation as a primary method of reimbursement. The ramifications of capitated health care are broad and warrant exploration from several vantage points. One basic concern in capitated health plans and managed care is the effect of new payment incentives on physician evaluation for purposes of credentialing. This Article focuses on managed care credentialing—the process of appointing, reappointing, and delineating clinical privileges—from a legal perspective. While the Article centers on the link between capitation and credentialing, it has broader applicability in that the same physician evaluation mechanisms in capitated settings are found in discounted FFS arrangements as well. The piece provides a brief overview of capitation and credentialing, and a discussion of trends that have altered hospital medical staff credentialing processes.

Causal Chains and Cost Shifting: How Medicare's Rescue Inadvertently Triggered the Managed-Care Revolution

2004 ◽  
Vol 16 (2) ◽  
pp. 144-174 ◽  
Author(s):  
Rick Mayes
Keyword(s):  
Health Care ◽  
Managed Care ◽  
Care Delivery ◽  
Health Care Delivery System ◽  
Dominant Mode ◽  
Market Forces ◽  
Fee For Service ◽  
Cost Shifting ◽  
Sequence Of Events ◽  
Business Behavior

The conventional wisdom on how managed care came to replace traditional fee-for-service reimbursement as the nation's dominant mode of health insurance is that enlightened businesses and their employers led the way in responding to the emergence of market forces in health care in the 1990s. A common textbook treatment of managed care's ascendancy puts it this way: “Transformation of the health care delivery system through managed care has been driven principally by market forces, and reinforced by government.” The irony is that the opposite sequence of events is a more accurate portrayal of what actually happened. As this article shows, the transformation of America's health-care system through managed care was initially triggered—albeit indirectly—by government actions and then driven by market forces. In other words, before business behavior was a cause of managed care's extraordinary growth, it was largely a response to and an unintended consequence of government policymaking: in this instance, Congress's reform of Medicare in 1983.

Direct Primary Care: A Successful Financial Model for the Clinical Practice of Lifestyle Medicine

2021 ◽  
pp. 155982762110066
Author(s):  
Amy R. Mechley
Keyword(s):  
Primary Care ◽  
Health Care ◽  
Care Delivery ◽  
Health Care Systems ◽  
Well Being ◽  
The United States ◽  
Fee For Service ◽  
Financial Model ◽  
Lifestyle Medicine ◽  
Direct Primary

Primary care has been shown to significantly decrease the overall cost of a population’s health care while improving the quality of each person’s well-being. Lifestyle medicine (LM) is ideally positioned to be delivered via primary care and has been shown to improve short- and long-term health outcomes of patients and populations. Direct primary care (DPC) represents a viable alternative to the fee-for-service reimbursement model. It has been shown to be economically and financially sustainable. Furthermore, it has the potential to fulfill the Quadruple Aim of health care in the United States. LM practiced in a DPC model has the potential to transform health care delivery. This article will discuss the need for health care systems change, provide an overview of the DPC model, demonstrate a basic understanding of the benefits, and review the steps needed to de-risk the investment of time, money, and resources for our future DPC providers.

Health Services Research at United HealthCare Corporation: The Role of the Center for Health Care Policy and Evaluation

1996 ◽  
Vol 53 (1_suppl) ◽  
pp. 65-76 ◽  
Author(s):  
Eileen Peterson ◽  
Deborah Shatin ◽  
Douglas Mccarthy
Keyword(s):  
Health Care ◽  
Managed Care ◽  
Health Services Research ◽  
Health Services ◽  
Health Care Policy ◽  
Research Priorities ◽  
Research Capacity ◽  
Lessons Learned ◽  
Services Research ◽  
And Performance

This article describes collaborative health services research and performance evaluation activities at United HealthCare Corporation, a national health care management services company. We outline the development of a research capacity within our company, the principal data sources used, and the types of research conducted. The importance of health services research within a managed care system is illustrated using two projects as examples. finally, we discuss issues faced by organizations such as ours in defining appropriate research priorities, ensuring health plan participation, and disseminating research findings. Lessons learned should be of interest to health services researchers working in or collaborating with managed care organizations as well as others seeking to understand the dynamics of research in private-sector health care companies.

Managed care Medicaid

2017 ◽  
Vol 11 (2) ◽  
pp. 198-210 ◽  
Author(s):  
William Trombetta
Keyword(s):  
Health Care ◽  
Managed Care ◽  
Health Care Delivery ◽  
Care Delivery ◽  
Care Quality ◽  
Market Segment ◽  
Economic Aspects ◽  
Content Type ◽  
The Poor

Purpose Providing health care to the poor is evolving in the new US marketplace. The Affordable Care Act has set goals enhancing access to health care, lowering costs and improving patient outcomes. A key segment in this evolution is the most vulnerable health-care population of all: Medicaid. This paper aims to provide a general review of how providing health care to Medicaid patients is changing including how socio-economic aspects of this vulnerable population affects the quality of the health care provided. Design/methodology/approach The paper is entirely secondary research; no primary research has been conducted. Findings Managed care Medicaid provides a risk-based model to treating a vulnerable health-care market segment. The jury is still out on whether managed care Medicaid (MCM) is improving health-care quality and saving cost, but the provision of health care to the Medicaid segment is definitely shifting from a fee-for-service model to value based payment. Very recent developments of new health-care delivery approaches present a positive outlook for improving quality and containing costs going forward. Research limitations/implications At this stage, whether or not MCM saves money or provides better health-care quality to this vulnerable population is a work in progress. Health-care marketing can impact socio-economic aspects of health care for the poor. There is a need to follow up on the positive results being documented in demonstration health-care delivery models. Practical implications At this point, there has been no long-term study of whether managed care Medicaid offers better quality of health care and cost savings. The research to date suggest that the quality of health-care delivery to the poor is improving at a lower cost to payers. Social implications Medicaid patients are an underserved market segment. Managed care Medicaid offers a new model that has the potential to provide quality care at acceptable cost. Critical to this vulnerable market segment is the need to integrate socio-economic aspects of the population with the delivery of health care. Originality/value There has been very little discussion of Medicaid overall in the marketing literature, much less any discussion of managed care Medicaid.

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