Effects of managed care on the proportion of inappropriate elective diagnostic coronary angiographies in non-emergency patients in Switzerland: a retrospective cross-sectional analysis.

OBJECTIVE: Guidelines recommend non-invasive ischaemia testing (NIIT) for the majority of patients with suspected ischaemic heart disease in a non-emergency setting. A substantial number of these patients undergo diagnostic coronary angiography (CA) without therapeutic intervention inappropriately due to lacking preceding NIIT. The aim of this study was to evaluate the effect of voluntary healthcare models with limited access on the proportion of patients without NIIT prior to elective purely diagnostic CA. DESIGN: Retrospective cross-sectional analysis of insurance claims data from 2012 to 2015. Data included claims of basic and voluntary healthcare models from approximately 1.2 million patients enrolled with the Helsana Insurance Group. Voluntary healthcare models with limited health access are divided into gate keeping (GK) and managed care (MC) capitation models. INCLUSION CRITERIA: patients undergoing CA. EXCLUSION CRITERIA: Patients<18 years, incomplete health insurance data coverage, acute cardiac ischaemia and emergency procedures, therapeutic CA (coronary angioplasty/stenting or coronary artery bypass grafting). The effect of voluntary healthcare models on the proportion of NIIT undertaken within 2 months before diagnostic CA was assessed by means of multiple logistic regression analysis, controlled for influencing factors. RESULTS: 9173 patients matched inclusion criteria. 33.2% (3044) did not receive NIIT before CA. Compared with basic healthcare models, MC was independently associated with a higher proportion of NIIT (p<0.001, OR 1.17, CI 1.045 to 1.312), when additionally controlled for demographics, insurance coverage, inpatient treatment, cardiovascular medication, chronic comorbidities, high-risk status (patients with therapeutic cardiac intervention 1 month after or 18 months prior to diagnostic CA). GK models showed no significant association with the rate of NIIT (p=0.07, OR 1.11, CI 0.991 to 1.253). CONCLUSIONS: In a non-GK healthcare system, voluntary MC healthcare models with capitation were associated with a reduced inappropriate use of diagnostic CA compared with GK or basic models.

Insurance product design and its effects: trade-offs along the managed care continuum.

This paper uses 1996-97 Community Tracking Study data to analyze the effects of different insurance product designs on service use, access, and consumer assessments of care for nonelderly people with employer-sponsored insurance. Product types are defined by features including use of networks, gatekeeping, capitation, and group/staff model delivery systems. We found no evidence of differences across product types in unmet need or delayed care or use of hospitals, surgery, or emergency rooms. At the same time, different product designs present purchasers with a clear trade-off between paying more out of pocket and encountering more administrative barriers to care. In addition, an increasing proportion of consumers report dissatisfaction with choice of physicians and low trust in physicians as one moves along the managed care continuum from unmanaged to heavily managed products. Our findings have implications for efforts to regulate managed care. The existence of a trade-off between out-of-pocket costs and administrative barriers to care means that some forms of regulation run the risk of reducing choices available to consumers. This is particularly true of regulations that would change the nature of managed care products by prohibiting the use of specific care management tools. To the extent that the backlash against managed care targets restrictions on choice and administrative hassles among consumers who nonetheless choose more heavily managed products because of their lower cost, eliminating heavily managed products would leave those consumers worse off.

A need for managed care in Saudi Arabia.

Is the Kingdom of Saudi Arabia getting value for money invested in health? Quality care is being provided throughout health facilities in the Kingdom, however there is minimal control of utilization in all health sectors, consequently leading to abuse and over utilization, particularly in the public sector. Managed care programs have proven effective in reducing unnecessary inpatient and ancillary service utilization by reducing use of expensive procedures and unnecessary, highly specialized services, and shifting to less expensive care options. Health maintenance organizations are the best example of a managed health care model; tracking good performance and cost savings averaging between 20-40% compared to more traditional health plans. Key features of health maintenance organizations include serving a defined population voluntarily enrolled in the health plan; assumption of contractual responsibility and financial risk by plan to provide a range of services, and payment of a fixed periodic payment by the enrollee, independent of the actual use of services. The key characteristic that distinguishes health maintenance organizations from other delivery systems is prepayment for the care that is provided. Preferred Provider Organizations offer discounts for services received from a selected set of physicians and hospitals. Services received by enrollees are not fully reimbursed from this selected list of providers. Preferred Provider Organizations use health maintenance organizations administrative processes for controlling costs but do not include some of the intrinsic cost and quality controls of health maintenance organizations. Review of several studies indicate that patients enrolled in prepaid group practices (managed care organizations) were hospitalized 15-40% less often than those enrolled in fee-for-service health plans.

Infertility services in a managed care environment.

Managed care schemes are replacing traditional fee-for-service reimbursement to physicians and hospitals in the United States. Managed care schemes take the form of discounted fee-for-service, utilization review, global fee reimbursement, and capitated reimbursement schemes with funds to be distributed among providers. Reimbursement for infertility services has been excluded from many managed care plans as infertility is viewed as a social condition, not a medical condition, and coverage for infertility diagnosis and treatment is viewed as unnecessary in the bundle of services offered by insurers and other managed care organizations. However, some states mandate infertility coverage and some managed care organizations realize that provision of care for infertile couples makes their product more attractive. Large managed care organizations such as Blue Cross/Blue Shield of illinois and some entrepreneurial organizations are developing managed care plans that incorporate infertility services. Comprehensive services--including in-vitro fertilization--can be offered at a lower cost than traditional fee-for-service care. Newer technologies such as in-vitro fertilization are replacing fallopian tube surgery and surgical treatment for male infertility. These can be implemented at a lower cost and with better outcome for infertile couples than traditional services.

Future shock: trauma in the managed care era.

This study examines the effects of managed care on the treatment of 1724 trauma patients seen over a 2-year period at an urban Level I trauma center. Fifty-one per cent of all trauma patients were insured. Managed care plans represented 42 per cent of the insurance coverage overall, increasing from 39 per cent in the first year to 45 per cent in the second. All treatment was provided by the receiving general surgery trauma team and was rendered independent of insurance status. Eighty per cent of patients completed their hospitalization at the trauma center. Clinical outcome, transfer rates, and mortality were similar regardless of insurance type. We conclude that managed care plans represent a significant and increasing portion of the insurance coverage of trauma patients, and propose that national guidelines should be developed to guarantee quality and continuity of trauma care.