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H. Michael Flasch, FHFMA, is vice president of claims/administrative services and support for Detroit, Michigan-based Health Alliance Plan (HAP), a subsidiary of Henry Ford Health System (HFHS), which also comprises [...]

Is this doctor's sentiment just an isolated case, or are more and more physicians and their patients beginning to feel that Utah's HMOs are too controlling? According to a recent [...]

After experiencing operating losses of more than $15 million and a growing number of days in accounts receivable and payment denials, Capital Health System implemented a multidisciplinary recovery program to [...]

Oxford CEO Dr. Norm Payson has his best physicians set the standard for healthcare policy DURING ANY DEBATE about a person's ability to lead, one of the first issues that […]

Harvard Pilgrim Health Care CIO Louis Gutierrez joined the financially troubled HMO in Jul 1999, at a time when it was beset by increasing difficulties, as are many others in the industry. Part of the problem at Harvard Pilgrim involved a diverse assortment of incompatible information systems inherited from mergers. Gutierrez decided to outsource most of the company's IT. Harvard Pilgrim was placed in receivership in Jan 2000, and although it was taken out of receivership in June, the health plan is still in the red. Harvard Pilgrim's prospects have improved, but no one is calling the company's situation a turnaround yet.

The rural population of California, which includes 17 percent of the population spread over 75 percent of the state, is experiencing serious health care problems. With six rural hospitals closing during 1998-2001, as well as a shortage of medical staff, lack of medical insurance and HMO access, the poor rural population must rely on doctors donating their time to provide basic medical care.

Disenrollment not of their choice from a Medicare managed care plan at an academic medical center has been found to arouse significant concerns for the patients, based on finding from a cross-sectional telephone questionnaire. The questionnaire was administered to patients of two outpatient clinics and involved 450 enrollees recently notified of termination.

A geriatric-approach case study of the Health Plan of Nevada's Social HMO implementation through autumn 1999 found that the plan reflects current perspectives on how to integrate chronic care into a health maintenance organization (HMO). Accomplishments affirm that the provision of risk-adjusted reimbursement, along with the 5% supplement to the normal Medicare payment, are incentive enough to get a health plan to place a priority on serving potentially expensive groups, including the elderly.

Physician perceptions of health maintenance organization (HMO) care for older patients have been studied based on 516 returned self-administered one-page questionnaires about HMO policies, impact of HMOs on physician practice, physician demographics, patient care, and respondents' personal use of managed health care plans. It was concluded that the majority of physicians in two nonprofit academically oriented Massachusetts Medicare HMOs perceived that overall quality of care for the elderly in an HMO was unchanged or got better.

The probable increase in HMO class actions arguing that the non-disclosure of physician compensation arrangements is a fiduciary breach is discussed. ERISA contains no implied disclosure mandate, and such suits can be interpreted as an attack against managed care itself.

Methods of physician profiling for health maintenance organizations are discussed.

Managed care is currently facing two difficult problems: rising costs and member dissatisfaction. By developing a supportive approach, based on quality performance, that includes disease management, case management, and preventive care, health plans can achieve increased savings. Their members will be happier and healthier as well.

An increasing number of health plans are initiating disease management programs, particularly for asthma, congestive heart failure and diabetes, in their effort to reduce costs without compromising the quality medical care they provide to patients. However, some of the programs are not producing cost savings. The reasons for the minimal cost savings include insufficient program design, ineffective management and unrealistic goals., The increased development and implementation of disease management programs reflect attempts by a growing number of health plans to reduce costs while providing patients with high-quality care. Unfortunately, few of [...]

Contact capitation is a payment system that gives physicians in health maintenance organization an opportunity to participate in savings they create. In this system, a specialist is paid according to the number of patients seen and not on the amount of office visits or services these patients receive.

KEY CONCEPTS * Physician Angst * The Importance of Values * Getting Back to Basics * Helping Physicians Cope with Change * Forces of Managed Care * Meaningful Physician Participation This article describes how the arrival of CEO J. Richard Gaintner, MD, at Shands HealthCare signaled a time for refocusing the organization's direction and helping physicians to cope with the changes buffeting the industry He saw angst and disenfranchisement, sentiments that characterized not only Shands and the University of Florida Health Science Center, but also the entire establishment of American scientific medicine. Gaintner believes--and continually preaches--that practicing medicine in a cost-effective manner will improve, not harm, the quality of care. His willingness to face reality objectively is perhaps his greatest asset in helping physicians deal with managed care. He conveys heartfelt empathy with the day-to-day conflicts they face. But he does not allow himself the temporary luxury of cynicism, and he refuses to accept negativity and pessimism in others. Rather, he asks that physicians and managers understand the system and develop the capacity to work within it and take responsibility for imp roving it. Beyond exhorting physicians to be accountable for the success of the enterprise, Gaintner creates mechanisms for meaningful physician participation in enterprise management., THE ARRIVAL OF A CEO generally signifies a major transition, as organizational styles merge and a new culture forms. In April 1997, J. Richard Gaintner, MD, became CEO of Shands [...]

This article examines how physicians act, react, and organize when managed care forces them to consolidate into larger groups and business corporations. Physicians have experimented with ownership by hospitals or business corporations to gain capital, management skills, and information systems. Now they're moving toward physician-owned groups with 'outsourcing' of administrative and information system functions. The mood, movement, and momentum of physicians, in short, is toward integrated physician organizations bound together by information that amplifies on their core competencies and capacities to deliver care. KEY CONCEPTS: Mood, Movement, and Momentum of Physicians and their Organizations, Managed Care Forces, Health Care Consolidation, Physician-Owned Groups, Integrated Delivery Systems (IDSs), 'AT THIS POINT, WE ARE not looking to anybody to come in and be the white knight to protect us and save us. We are simply going to have to [...]

Healthcare organizations require corporate compliance programs for their integrated delivery systems to ensure their commitment in legal and ethical operations. These organizations must avoid the common obstacles in the development of the compliance programs such as cost, time allocation, lack of necessity and effects on the morale on employees. The compliance program development has four phases: identification of compliance risk, implementation of the program, auditing of claims processes and continued monitoring and training., A compliance program in an integrated delivery system (IDS) must facilitate coordinated compliance efforts across all of the health system's components (eg, flagship hospital and attendant home health agency, nursing [...]

Health maintenance organizations (HMOs) can improve member retention for their managed care plans by explaining the value of customer loyalty to employees and senior management. This can be done by educating executives and staff about the full cost of lost members compared with the benefits of member retention and loyalty. It is also advisable to form a cross-functional team whose sole responsibility is member retention. Another helpful strategy is to determine why members and payers leave health plans and develop the necessary plan of action., Although most plans measure member satisfaction, this measure is not an accurate indicator of member retention. Plans reporting 90 percent satisfaction rates also report disenrollment rates of 20 to 40 [...]

The debate over managed care is polarized, with critics seeing little virtue and defenders finding little fault. In fact, managed care has considerable potential to improve health outcomes while lowering costs. However, it can also spawn practices that jeopardize health care quality and access. This article explores the challenge of capturing and building on the many strengths of managed care while curbing its excesses.

Stand-alone long-term care providers are leveling the playing field for managed care contracting A problem plaguing the stand-alone long-term care residential community is that it is usually at a disadvantage [...]

The current environment of the managed care industry as of Jul 30, 1998, along with an industry profile is presented, including key ratios and statistics, industry operations, and trends. A comparative company analysis, industry references, and a glossary are also given.

In traditional geriatric medicine, comprehensive assessment is considered crucial to the care of frail older patients. The principles of geriatric assessment - identifying high-risk patients and targeting them for preventive interventions - are also practiced by managed care organizations (MCOs). Self-reported health surveys and administrative data are two methods used by MCOs to identify members at high risk for adverse health outcomes and functional decline who may benefit from geriatric case management. For a successful partnership with primary care physicians, it is very important that geriatric care managers should be knowledgeable in the principles of geriatric medicine., Comprehensive geriatric assessment is considered by most geriatricians to be an important and effective form of secondary and tertiary preventive care for the frail elderly.[1-3] In traditional fee-for-service (FFS) medicine, [...]

Managed care has become a hot topic in the Indiana business community in recent months. The state's business executives have been hearing about health-maintenance organizations, preferred-provider organizations and gatekeepers to [...]

To some, it is a distant prospect - but the opportunities are real and worth considering With the growth of the assisted living population, managed care companies (MCOs) are looking [...]

With both HMOs and hospitals consolidating to compete, both are trying to demonstrate 'value' to their customers. State health officials and industry executives estimate that at least 50% of all [...]

With increased use of managed care, corporate benefits departments are facing new challenges, such as communicating benefits options to a more knowledgeable work force, dealing with upheaval caused by mergers and acquisitions, and centralizing benefits administration. The authors illustrate how some of these challenges are being met today through HMO network management.

I. INTRODUCTION A. The National Character of the Health Maintenance Organization Industry and the Need for Reform Accompanying its expansive growth over the last fifteen years,(1) the health maintenance organization [...]

Just a few years ago, reformers proclaimed that managed care would transform America's decrepit health insurance program for the poor into a gleaming model of market efficiency and quality--and solve [...]

Kaiser Foundation Health Plan Inc., the nation's first and largest health maintenance organization, is suffering from poor public relations that have tarnished its former image of being an exemplary healthcare provider. Kaiser is a massive non-profit, integrated healthcare delivery system, and evidence seems to reveal that it is a quality leader in many healthcare areas, and that its quality is improving., Kaiser is the best of HMOs, Kaiser is the worst of HMOs. To its supporters, Kaiser Permanente is what an HMO should be: an integrated and cost-effective healthcare delivery system [...]

Los Angeles County, California created a health maintenance organization network, L.A. Care Health Plan, to treat the county's 1.2 million recipients of Medi-Cal, the state's Medicaid program. Medicaid services will be administered under a managed care system that consists of L.A. Care and a commercial HMO, FHS, that compete against each other for enrollees. L.A. Care consists of six private and one public managed care health providers., Despite initial applause, the future of L.A. County's two-plan model for serving Medicaid beneficiaries remains uncertain There was much rejoicing in April when L.A. Care Health Plan, one of two [...]

Several provider systems were forced to sell their health maintenance organizations (HMOs) to large for-profit managed-care organizations in 1996 in the face of stiff competition, mergers and buyouts in the healthcare industry. Despite the pressure to sell, some not-for-profit plans have vowed not to sell, although they made smaller profits or posted losses., HMOs, PPOs in flux as buyouts, mergers, competition take a toll on the market As market competition continued to take its toll in the past year, several provider systems sold [...]

The change from a fee-for-service system to a managed care system shifted greater financial responsibility for health care to patients. This means that patients will expect health care providers to function like other consumer services. Health care providers can adapt to the changes in the health care environment by putting emphasis on benefits and not on features. Best practices can be learned and applied to the health care environment by studying other consumer service industries., It is quiet now, as it must have been in 1788 Pads or 1916 St. Petersburg. Consumers quietly took $203 billion from their own pockets and spent it on health [...]

MacNeal Health Network has implemented a computer-based patient record system in its outpatient clinics that improves efficiency by eliminating paperwork. This computer-based approach has been successful because of physician support. Management phased in the system based on the readiness and enthusiasm of physicians in different clinics, assuming that word of mouth would interest others. The MacNeal organization has invested a great deal of capital in this project, and the only obstacle to bringing the system into inpatient medicine is the lack of additional capital. MacNeal has conserved some funds by not integrating decision support capabilities into this system.