Chapters four through six described, evaluated, and reviewed the 25 Medicaid programs. The authors developed a typology to classify the various programs into six categories and ultimately built a systematic body of knowledge on PCCM in the Medicaid context. They further evaluated cost and use outcomes regarding PCCM and gatekeeping for physician visits, emergency room visits, ancillary services, prescription drug use, inpatient use, and costs. The last two chapters discuss policy implications and study limitations. Major implications for the managed care reformer include the
During the 1980s, prescription drug costs increased faster than other components of the Medicaid budget. In 1980, total vendor payments for prescription drugs were $1.3 billion, or 5.7 percent of all Medicaid expenditures. By 1990, prescription drug expenditures had risen to $4.4 billion, or 6.3 percent of the Medicaid budget (National Pharmaceutical Council 1991). Faced with this expenditure pattern and increasing federal deficits, Congress included a provision in the Omni-
Compared to its near-decade of influence in manufacturing and in several service sector industries, total quality management (TQM) has only recently been applied to health care. Since the early calls for action by Berwick and others beginning in 1988, and adoption of the quality management paradigm by the Joint Commission for Accreditation of Health Care Organizations (JCAHO), 58.5 percent of acute care hospitals &dquo;have a TQM/CQI program in place&dquo; (Grayson 1992, 25; Berwick 1988; Carroll 1991; Milakovich 1991; McLaughlin and Kaluzny 1990; Kaluzny, McLaughlin, and Kibbe 1992). Of those hospital chief executive officers who do not have a TQM program in their institution, 78.2 percent plan to start one within the next year (Grayson 1992). Only
The medications that are being made available upon demand are not just those that &dquo;relieve symptoms of minor, self-limiting conditions.&dquo; They include medications of substantial importance that &dquo;prevent diseases&dquo; and &dquo;manage chronic conditions&dquo; (Young 1988, 6).5 Future switches are likely to continue in this direction. For example, Shering Plough Health Care will apply to the Food and Drug Administration (FDA) to sell oral contraceptives over the counter (Angier 1993). Neither are the financial dimensions of the Rx-to-OTC switch trivial. Switched
common sight in the health press. The president of the American Hospital Association, for instance, urged hospitals to move into a &dquo;new era of cooperation&dquo; in order to meet community health needs.1 Unfortunately, cooperative efforts among hospitals may often fail, in spite of the potential gains from cooperation. The explanation for this conundrum lies in a model called the prisoner’s dilemma. The prisoner’s dilemma, which describes a situation in which deci-
Over the past few decades, economic, legal, technological, demographic, and political changes in the social context of health care in the United States have produced significant modifications in perceptions and expectations of the health care system. The quality of care provided within health services institutions, encompassed within the catch phrase &dquo;continuous quality improvement&dquo; or &dquo;total quality management,&dquo; is a focus of much discussion and even a mandate by the Joint Commission on Accreditation of Healthcare Organizations (JCAHO). Specific methods of quality improvement remain questionable; yet multidisciplinary collaboration and teamwork have been identified by
In summary, the managed care system we propose for preventive services is designed to limit the potential for overcare under FFS payment and for undercare under capitation and comprehensive fixed fees. It bases payment on the provision of a complete set of preventive services, thus limiting the tendency of physicians to provide only the relatively high-profit services, such as screening tests, while neglecting the lower-profit services, such as counseling. It also allows primary care providers to outsource selected services to lower-cost providers, such as laboratories, health educators, and counselors, and community-based health promotion programs, thus encouraging greater efficiency. In addition, the proposed system funds both primary and high-risk preventive case management to ensure that individuals receive preventive services appropriate to their age, sex, and risk factors. Finally, the proposed system monitors the use of preventive services, relying on physician reminders to stimulate the appropriate provision of preventive care and denying payment for unauthorized care. Existing research suggests that none of the individual strategies for managed care can be expected to achieve all of the goals of managing and promoting the appropriate use of preventive services as defined by the U.S. Preventive Services Task Force (1989). To be most effective, we conclude that the strategies need to be coordinated and integrated into the current health care delivery practices of HMOs, PPOs, and point-of-service plans. In addition, the strategies require additional provider training in preventive care. With this support, the proposed model has the potential to improve quality, control costs, and increase the appropriate use of preventive care. While many of the individual components of the proposed managed care model have been evaluated for preventive services, a great deal more research is needed to evaluate the effect of combining these elements into a coordinated and comprehensive approach to managing preventive care. Research is also needed on workable ways to invite people not currently receiving medical care into the health care system to receive preventive care. To inform policy development, the impact of the proposed managed care model--both on preventive services utilization for specific screening, immunization, and counseling services, and on total health care costs and patient health status outcomes--needs to be evaluated.
