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Managed Care Systems and Emerging Infections: Challenges and Opportunities for Strengthening Surveillance, Research, and Prevention, Workshop Summary 1 Introduction BACKGROUND* As dramatic restructuring of the nation's health care system evolves, managed care organizations will likely have a major effect not only on health care delivery but on many other aspects of the public health enterprise as well. Specifically, the fight against infectious diseases—through prevention, surveillance, treatment, and research—represents one of many areas in which managed care organizations have the potential to make marked improvements to a community's health. To make such a contribution, however, controls on reimbursements for health care expenditures must be carefully considered as they may pose an impediment to effective collaboration among managed care organizations and the public health community, Over the last 20 years, managed care has come to dominate health care delivery in the United States; more than 150 million Americans participate in health insurance arrangements that fall under the diverse umbrella of ''managed care" (Miller and Luft, 1994). This development illustrates a trend from an alliance between providers of care and insurers under the traditional fee-for-service indemnity arrangements to the current systems in which insurers work more closely with large, group payers—primarily employers and government agencies (Rosenbaum et al., 1997). The term managed care encompasses a broad variety of arrangements, many of which continue to evolve as they adjust to market pressures. Generally, in a managed care system, health plans attempt to coordinate and thereby control the use of medical health care-related services (specialty visits or emergency care) by restricting reimbursement for services. Purchasers of health * This evaluation is based on the opening remarks of Margaret Hamburg, M.D.. Assistant Secretary for Planning and Education, U.S. Department of Health and Human Services; additional sources are listed in the references section.
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Managed Care Systems and Emerging Infections: Challenges and Opportunities for Strengthening Surveillance, Research, and Prevention, Workshop Summary care services contract with managed care organizations, which then select providers or groups of providers to care for an enrolled patient population. A patient either selects or is assigned a provider, typically a primary care physician who may have received special training in managing care and who may also have financial incentives to manage that care effectively. Such physicians often act as gatekeepers for access to additional specialty services because of the restrictions placed on reimbursements for specialty service provisions. Ideally, the system operates to reduce unnecessary services for health care, allowing managed care organizations to decrease their overall costs. Theoretically, purchasers enter into contracts with managed care organizations largely on the basis of cost, the benefits package, and quality, thus creating the incentive for these organizations to offer superior services and consumer-oriented benefits. A competitive environment has produced variations in organizational structures as managed care groups attempt to balance the financial risks of cost-control measures with the provision of quality health care (Association of State and Territorial Health Officials, 1995). Managed care thus has evolved into several types of health plan structures, including health maintenance organizations (HMOs); the staff model, group model, and network model HMOs; individual practice association model and mixed model HMOs; preferred provider organizations; point-of-service plans; physician-hospital organizations; and management services organizations. Table 1-1 describes the types of managed care organizations. Appendix B is a glossary of terms and acronyms commonly used in the managed care industry and encountered throughout this workshop summary. An effective health care delivery system depends on the availability of a continuum of different types of services, ranging from research to clinical services to public health programs. As it has evolved, managed care has influenced each of these elements of the continuum, creating new pressures, as well as providing novel opportunities. Although several areas of health care in the present system are encountering difficulties, certain aspects of managed care, primarily its emphasis on prevention, should give the public health community reasons for optimism. Some of the benefits from an emphasis on prevention include the following: the ability to deliver a range of clinical preventive services such as immunizations and screening for infectious diseases; the increase in incentives to link clinical preventive services with community-based prevention through educational outreach and behavior modification efforts; the data collection systems that may complement public health efforts aimed at communicable disease monitoring and quality assurance; and the organizational structures of managed care entities, particularly those that use selected providers and that have explicit expectations or requirements for certain clinical practices, which may prove valuable in enhancing disease reporting, disease management, and quality assurance.
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Managed Care Systems and Emerging Infections: Challenges and Opportunities for Strengthening Surveillance, Research, and Prevention, Workshop Summary TABLE 1-1 Types of Managed Care Organizations Type of Organization Description HMO Organized system of health care that arranges a comprehensive range of health care services to a voluntarily enrolled population in a geographic area on a primarily prepaid and fixed periodic basis. Staff model HMO HMO in which practitioners are salaried employees of the HMO. The practitioners may also receive a bonus or other incentive income. Group model HMO HMO in which an organized group of practitioners contract with an HMO to provide services, often on a mutually exclusive basis. The provider organization receives a negotiated, per capita payment, which may be distributed to individual clinicians by salary, capitation payments, fee-for-service reimbursements, or incentive payments. Network model HMO HMO which contracts with individual clinicians, groups or IPAs, and hospitals to provide care. The contracts are usually not exclusive, and providers may be paid by capitation, fee-for-service, or other mechanisms. Clinicians may contract with the HMO directly or through an intermediary organization such as a medical group or IPA. Individual practice association model A model in which an HMO contracts with independent practice associations (IPAs) to provide care. The IPAs are generally directed and often owned by member providers who retain their independent practices but use the IPAs to obtain managed care contracts and, on occasion, to administer care-related services. Mixed model Combination of two or more of the above. Preferred provider organization (PPO) Network discount, fee-for-service provider arrangement in which patients are given incentives to stay inside the network; receipt of services outside of the PPO network are allowed with an increased copayment or deductible; a PPO has some structured quality and utilization management. Point-of-service plan Organized system of health care provided by an HMO model with the option of the delivery of services outside of the network with a higher copayment or deductible. Physician-hospital organization (PHO) Legal entity formed or owned by hospitals and physicians to obtain payer contracts; physicians may retain ownership of their practices but agree to accept managed care patients under terms negotiated by the PHO. Management services organization Organization that provides practice management, administration, and support services to individual physicians or group practices. SOURCE: Adapted from IOM, 1997a.
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Managed Care Systems and Emerging Infections: Challenges and Opportunities for Strengthening Surveillance, Research, and Prevention, Workshop Summary In the clinical setting, because managed care organizations provide health care services to an enrolled population, they have the capacity to provide patient follow-up, as well as to monitor treatments and outcomes across a range of important clinical research areas, including patterns of antibiotic use and resistance, control of nosocomial infections, and investigation and evaluation of new screening strategies or diagnostic methods. These capabilities are particularly important in the monitoring and control of emerging infections. In many ways, managed care organizations also may have an advantage over other systems of health care in providing increased accountability for the appropriateness and quality of clinical care. Many managed care organizations have the infrastructure to improve surveillance through (1) systematic collection of relevant data from the health care provider's first encounter with a patient, including all information important to communicable disease reporting; (2) standardization of computerized systems that can monitor health data; and (3) education of providers regarding the importance of their role in accurate disease reporting. The Health Plan Employer Data and Information System (HEDIS), which was developed by a coalition of health plans, employer purchasers, and the National Committee for Quality Assurance, uses standardized measures to evaluate performance in quality of care, access and satisfaction, membership and utilization, finance, and health plan management. The current HEDIS structure serves as an important first step in gathering standardized data for evaluation of managed care systems, but until there is more widespread adoption of uniform standards across managed care plans, its value will be less than optimal. Although trends indicate that managed care is making some progress in the fight against infectious diseases, they also indicate potential problems for both health care providers and consumers. The emphasis on controlling the costs of reimbursement for health care services can lead to an incorrect or missing diagnosis, underreporting of some infectious disease conditions, and inadequate follow-up. Moreover, the move within managed care toward treatment of infectious diseases by general practitioners rather than specialists—perhaps beneficial in terms of cost control and of broader attention to a patient's complaints—may weaken infectious disease control. The complexities of today's emerging pathogens require more multifaceted regimens for the appropriate management of patients and tracing of the source of exposure. Human immunodeficiency virus infection-AIDS presents a good example: the knowledge base is evolving so rapidly and some of the treatment regimens require such sophisticated knowledge of the disease, its progression, and available therapy that the best treatment often lies outside the realm of primary care. Thus, to achieve appropriate management of complex infectious diseases, managed care organizations might have to implement guidelines and oversight that reflect the expertise of infectious disease specialists or ensure the excellent integration of specialty care expertise into clinical services.
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Managed Care Systems and Emerging Infections: Challenges and Opportunities for Strengthening Surveillance, Research, and Prevention, Workshop Summary The shift from inpatient to outpatient treatment, which is more pronounced in managed care organizations, has also raised challenges for infectious disease reporting. The outpatient care setting is not likely to have the necessary infrastructure for disease reporting commonly found in the inpatient care setting. This includes a dedicated hospital epidemiologist or infectious disease specialist who understands the reporting rules and requirements, who is responsible for reviewing cases and reporting diseases, and who has an established and effective relationship with the state or local health department. An emphasis on outpatient treatment could encourage less reliance on laboratory testing and subtyping of isolates, with subsequent deficiencies resulting in the typing of the infecting pathogen. Insufficient disease reporting through these traditional mechanisms could impair disease control efforts, as well as the identification and tracking of potential outbreaks. Additionally, the various laboratory and treatment practices of managed care organizations, including contracting with laboratories remote from the origin of the specimen, can make the recognition of, reporting, and response to an outbreak less reliable. Yet managed care organizations cannot be expected to assume all of the traditional functions of the public health systems, especially when deficiencies already exist outside of managed care. For example, the observation of compliance with the treatment regimen for patients with tuberculosis or panner notification and contact investigation for patients with sexually transmitted diseases are generally beyond the capacities of managed care systems. Moreover, managed care systems have neither the resources and expertise nor the mandate and authority to replace public health programs designed specifically to protect the community's health. Thus, partnerships between managed care and the public health community are required to shield already strained public health infrastructure from further stresses. The need for collaboration is even more important in light of the reality that managed care organizations increasingly are becoming the major mode of health care delivery and financing for publicly funded care and the Medicaid and Medicare programs (CDC, 1995). Many state governments have chosen managed care to provide health care services for individuals enrolled in state Medicaid programs, creating the "managed Medicaid" model. Local decision makers have redirected significant resources from public health system programs to managed care systems, believing that managed care systems are an alternative source for the provision of services. However, managed care does not always fully integrate public health system programs. An additional concern for the public health community is the effect of the increasingly competitive nature of the health care market on publicly supported services, including clinical services and broader public health programs that require effective linkage with clinical services. An unintended consequence of market competition on clinical services and public health programs may be a reduced capacity over time of academic health centers to support both research and training, activities that have traditionally relied on a healthy combination of service-related revenues and public financing. The responsibilities of basic and
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Managed Care Systems and Emerging Infections: Challenges and Opportunities for Strengthening Surveillance, Research, and Prevention, Workshop Summary clinical research and training may disproportionately fall on public-sector institutions, such as the U.S. Department of Veterans Affairs (VA), the largest provider of health care training in the United States and one of the largest research organizations in the world (Appendix A). The transformation of the U.S. health care system to one of managed care may be the single most important development in health care delivery since the rise of modern medicine and the advent of health insurance. Because managed care organizations now claim enrollment of more than 150 million Americans, this transformation has not only altered the relationships between patients and independent providers but has also changed Medicaid from a fee-for-service government health insurer into a large-scale purchaser of private insurance. To improve health outcomes, public and private purchasers of health care—particularly large employers, the Health Care Financing Administration, and state Medicaid agencies—should form partnerships with public health agencies (CDC, 1995). These new arrangements, combined with collaborative efforts with managed care organizations, could greatly improve community health while containing health care costs. Clearly, assessment of the impact of managed care on the control of emerging infectious diseases is complicated by the rapidly changing environment of the U.S. health care system. Managed care is changing the type and quality of health care that many Americans receive. By promoting the integration of health care services, including public health, managed care could enhance not only the continuity of care but its quality as well. ABOUT THE WORKSHOP AND ORGANIZATION OF THE WORKSHOP SUMMARY Jonathan R. Davis, Ph.D., Editor In the rapidly changing environment of health care delivery and financing, the impact of managed care on infectious disease surveillance, research, and prevention impelled this workshop on the part of the Institute of Medicine (IOM) Forum on Emerging Infections to assess the opportunities and challenges posed by changes in this environment. In developing the workshop agenda, Forum members identified five key areas for discussion: (1) basic and clinical infectious disease research, (2) clinical practice guidelines, (3) emerging infections surveillance and monitoring, (4) education and outreach, and (5) drug formularies and product development. This workshop summary is organized according to these five key areas (Chapters 2 to 6, respectively), followed by concluding remarks (Chapter 7), references, and a series of appendixes (Appendix A, the Veterans Health Administration and Infectious Disease; Appendix B, Glossary and Acronyms; Appendix C, Workshop Agenda; and Appendix D, Forum Member and Staff Biographies).
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Managed Care Systems and Emerging Infections: Challenges and Opportunities for Strengthening Surveillance, Research, and Prevention, Workshop Summary The managed care environment is diverse, and for the purposes of this workshop summary, only for-profit types of managed care organizations are considered in detail. However, in addition to non-profit and for-profit organizations, other significant players are governmental, including the VA and the U.S. Department of Defense. Of particular note, the VA has the largest fully integrated health care system in the world and is the only national safety net for many highly vulnerable patients. Appendix A presents an overview of VA health care systems with regard to emerging infections and managed care. Representatives from managed care organizations, hospitals, government agencies, pharmaceutical companies, and academia were invited to give panel presentations moderated by Forum members. Each panelist was asked to highlight important issues, suggest possible practical solutions, and recognize impediments that must be overcome. By the end of the workshop discussions, participants noted that no two managed care organizations are identical. Moreover, the Forum members and participants recognized that the information cited may be unrepresentative of managed care organizations and that additional presentations from managed care organizations were needed for a greater exploration of the subject, Thus, by default, the workshop focused on a few model systems to stimulate discussion and to provide examples of successful programs. In identifying organizations that could serve as examples of organizations whose practices effectively fight infectious diseases, the Forum recognized the Group Health Cooperative of Puget Sound for its leadership in research, the National Independent Practice Association Coalition and the Healthcare Education and Research Foundation for examples of clinical practice guidelines, the Harvard Pilgrim and Latter-Day Saints Hospital as models of effective surveillance and monitoring systems, and the Group Health Association of America for its guidance in educational and outreach programs. Through the workshop the Forum has identified some examples of best practices in managed care and infectious disease control, and through this workshop summary it hopes to disseminate information on why certain programs are effective, as well as provide for others guidance on how to achieve positive results in a variety of settings. This report of the Forum-sponsored workshop is prepared in the form of a workshop summary by and in the name of the editor with the assistance of staff and consultants, as an individually authored document. Sections of the workshop summary not specifically attributed to an individual reflect the views of the editor and not those of the Forum on Emerging Infections. The content of those sections is based on the presentations and the discussions that took place during the workshop. Accordingly, each of the next five chapters begins with an opening statement of context and background authored by the editor, followed by descriptions of the presentations that were made by invited participants. At the end of each of these chapters is a summary by the editor of the issues and themes that emerged from the presentations and during the discussions. The last chapter contains concluding remarks authored by the Chair of the Forum.
Representative terms from entire chapter: