Changing Health Care Systems and Rheumatic Disease (1996) / Chapter Skim
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9: How Easily Do Health Care Systems Adopt New Knowledge, and What Are the Likely Future Developments?
9: How Easily Do Health Care Systems Adopt New Knowledge, and What Are the Likely Future Developments?
Pages 169-188
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From page 169... ...
9 H~ Emit Do Hemp Care Ems Adopt Knowledge, and ~ba1 Are Be Likely Future Developments?
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From page 171... ...
His own review of the literature suggests that actual outcomes for patients with chronic diseases in fee-for-service (FFS) and managed care systems yielded little difference, with the possible exception of slightly decreased patient satisfaction in managed care associated with access to services.
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From page 172... ...
Both Robbins and McGarvey point out that managed care can neither substitute for nor adequately address health care issues that are essentially social in nature, including coverage of the uninsured.
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From page 173... ...
There are a number of issues here, but I will try to keep the focus on how financial incentives are likely to impact adoption of new organizational knowledge by managed care organizations. I also will review the characteristics of evolving "model systems" that appear to provide good, integrated services at reasonable cost to frail elderly patients in managed care.
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From page 174... ...
. Patients receiving coverage under SSDI, and therefore eligible for Medicare capitation rates based on the average cost of a disabled person in that county, may have a capitation rate far higher than a similar individual who does not receive SSDI eligibility-and physicians say eligibility determination can be quite arbitrary for a disease .
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From page 175... ...
Given the high disenrollment rates for Medicare and Medicaid managed care patients, good, comprehensive medical care that prevents expensive utilization in the long term is not likely to be viewed as of much financial value to the HMO unless it generally enhances the HMO's reputation. Indeed, by making it difficult for costly, chronic care patients to access certain types of services, the HMO may be able to increase disenrollment and decrease future enrollment of these less profitable patients.
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From page 176... ...
In each case, subspecialists act as consultants to primary care physicians and as head of a team that will take over management when long-term care services are required. Physician assistants and allied health professionals working in the team are assigned to given patients and have the most direct contact with them.
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From page 177... ...
Manheim's presentation by providing an overview of the forces that are shaping the health care industry, the incentives that are influencing decisions at the patient and provider levels, and the changing nature of these incentives. I think that only by understanding these forces and their dynamics can we acquire insight into the critical issue of whether competition in health care will take place on the basis of innovations designed to enhance quality, thereby encouraging the adoption of new knowledge and improved chronic disease management, or based on potentially less desirable factors.
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From page 178... ...
The accelerated and sometimes frenetic cascade of mergers and acquisitions among health plans and hospitals has led to new and sometimes dysfunctional delivery systems and has raised the critical issue of what the essential components of a truly integrated delivery system are. It has also raised the questions of what is the most effective model or mixture of models (independent practice association(IPA)
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From page 179... ...
One can certainly argue that the growth of overlapping IPAs is an effective way to force health plans to compete on price. Cost containment is something we have been talking about quite negatively today the shift from inpatient to outpatient treatment; primary care gatekeepers limiting specialty access; the heavily discounted feefor-service policies that were initially tried to control costs; and capitation, which followed and is gradually marching from west to east.
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From page 181... ...
I think Larry Manheim asked a very important question concerning the basic modes of adopting new technology in different managed care systems. That is, who is the decision maker?
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From page 182... ...
On balance then, I would say, just as Karen Davis outlined a number of theoretical pros and cons of managed care, that one of the pros is that in a managed care environment there is, in fact, a structured approach to technology assessment, adoption of new technology, and investing in new technology for actual application by practicing physicians helping to shape that system. One of the myths I would like to address here is that managed care organizations behave without any clinical input.
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From page 183... ...
I think it is important to remember that the prepaid group practices that were the progenitors of our managed care entities today developed essentially to take care of working populations-younger people who were involved in a job and needed health care, and whose organizations paid for it. It is very much in the tradition of American insurance that it has been employment based.
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From page 185... ...
Particularly since we are talking about vulnerable populations, do you see any incentives or disincentives, or any problems with that community care safety net and the integration of health plans into it, utilizing its resources or augmenting them for their own benefit? LARRY MANHEIM: To the extent that community care will save money on some cost that these plans would otherwise bear, capitated care systems might put money there.
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From page 186... ...
I think it would be good to involve chronic disease patients, but you must have a payment system that supports that kind of interaction. NORMAN LEVINSKY: With regard to the issue of the disadvantaged, I would mention that there is an experiment going on, largely funded by Medicare, dealing with the frail elderly.
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From page 187... ...
Do you think managed care organizations would put a portion of their income into government systems to enhance the care for the vulnerable populations? MICHAEL MCGARVEY: Although our HMO is technically a for-profit subsidiary, any sensible financial analyst looking at our medical loss ratio would question whether this is an accurate characterization.
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From page 188... ...
One of the recommendations, in fact, was that the clinical center be a little more aggressive about contacting managed care organizations for case finding. If things were structured properly and if people understood the ground rules, this it would be a very fertile area for patient identification.
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