HMOs don't have to fail

One of the bright spots in the sometimes black picture that is painted of our national health care system is HMOs. Health maintenance organizations provide health services to an enrolled group of patients for a fixed, prepaid fee. This arrangement induces HMOs to try to keep patients healthy for a competitive rate. Because of its special nature, however, an HMO cannot be managed like a fee-for-service hospital or group practice. And because few managers fully understand them, more and more HMOs are failing. The authors of this article say, however, that some failures can be avoided. Good management techniques can help HMO managers-whether they are community-spirited citizens or seasoned executives-overcome many of the problems that plague HMO plans: out-of-control utilization rates, growth that can occur overnight, conflict between the values of HMOs and of the physicians that staff them, and competitors in the health field.     

A Comparison of HMO Efficiencies as a Function of Provider Autonomy

Current debates in the insurance and public policy literatures over health care financing and cost control measures continue to focus on managed care and HMOs. The lower utilization rates found in HMOs (compared to traditional fee‐for‐service indemnity plans) have generally been attributed to the organization's incentive to eliminate all unnecessary medical services. As a consequence HMOs are often considered to be a more efficient arrangement for delivering health care. However, it is important to make a distinction between utilization and efficiency (the ratio of outcomes to resources). Few studies have investigated the effect that HMO arrangements would have on the actual efficiency of health care delivery. Because greater control over provider autonomy appears to be a recurrent theme in the literature on reform, it is important to investigate the effects these restrictions have already had within the HMO market. In this article, the efficiencies of two major classes of HMO arrangements are compared using “game‐theoretic” data envelopment analysis (DEA) models. While other studies confirm that absolute costs to insurance firms and sponsoring companies are lowered using HMOs, our empirical findings suggest that, within this framework, efficiency generally becomes worse when provider autonomy is restricted. This should give new fuel to the insurance companies providing fee‐for‐service (FFS) indemnification plans in their marketplace contentions.     

Why Are Managed Care Plans Less Expensive: Risk Selection,Utilization, or Reimbursement?

This article develops a new method of decomposing the cost difference between HMO and non‐HMO plans into observed risk selection, unobserved risk selection, utilization differences, and differences in provider reimbursement rates. We implement this method using a large national sample of employer‐sponsored health insurance enrollees from the Community Tracking Study Household Survey. We find no evidence that HMO plans attract a disproportionate share of low‐risk enrollees; the US$188 difference between HMO and non‐HMO medical expenditures per enrollee can be explained by the relatively low provider reimbursement rates paid by HMO plans. This indicates there may be little need for employers to risk adjust insurance premiums or otherwise restrict employee choice of plan types.     

Managed care, consolidation among health care providers, and health care: evidence from mammography

We discuss the effects of managed care on the structure of the health care delivery system, focusing on managed-care-induced consolidation among health care providers. We empirically investigate the relationship between HMO market share and mammography providers. We find evidence of consolidation: increases in HMO activity are associated with reductions in the number of mammography providers and with increases in the number of services produced by remaining providers. We also find that increases in HMO market share are associated with reductions in costs for mammography and with increases in waiting times for appointments, but not with worse health outcomes.     

Measuring the economic value of HMOs

The economic efficiency of HMOs varies dramatically, affected by such factors as market share, provider contracting agreements and utilization management techniques. Employers that establish HMO strategies without conducting quantitative assessments may incur unnecessary costs. A combination of both quantitative and qualitative analyses can lead employers to a best practice system of health care.     

Linking Internet strategy to high-quality, cost-effective managed care

This article describes an experimental pilot project incorporating e-commerce and the Internet into the traditional process of health benefit negotiations through the utilization of an HMO Internet auction. The timeline and process of the auction are described, with the final auction taking place during the last week of negotiations. The results reveal an efficient and effective system to augment the traditional benefit negotiation process.     

残疾人综合服务设施利用情况研究——基于四川省成都市的调查

本文对成都市残疾人联合会下属的成都市残疾人综合服务中心、郫县残疾人综合服务中心和邛崃市残疾人综合服务中心的资源利用情况进行了全面调查,通过比较人均面积、空间利用率、单位面积服务人次和设施使用频次等4个指标,发现残疾人综合服务中心资源有效利用率不足。究其原因有两个方面,即残疾人综合服务中心的行政管理导向和供需结构性矛盾。     

Fiduciaries--HMOs--incentives to ration care. Pegram v. Herdrich

Pegram v. Herdrich, ___ U.S. ___, 120 S. Ct. 2143 (June 12, 2000): An HMO cannot be liable for breach of fiduciary duty because of mixed eligibility decisions by its doctors, even if the HMO gives the doctors financial incentives to minimize care because treatment decisions made by an HMO through its physician employees are not fiduciary acts within the meaning of ERISA. Where eligibility for benefits depends upon decisions by doctors concerning their conclusions about when to use diagnostic tests, when to authorize consultations or make referrals, proper standards of care, whether a proposed treatment is experimental, the reasonableness of certain treatment, and the emergency nature of a condition, such "mixed eligibility decisions" are not fiduciary acts under ERISA, and an HMO will not be treated as a fiduciary to the extent it makes such decisions through its doctors.     

HMOS--independent medical review--preemption. Rush Prudential HMO,Inc. v. Moran

A state statute can require an HMO to provide for an independent medical review of a denial of a request for a particular treatment as not medically necessary and to provide the treatment if the reviewing physician determines the covered service is reasonably necessary. The statute is exempt from ERISA preemption as a law that regulates insurance.     

Managed care,technology adoption,and health care: the adoption of neonatal intensive care

Managed care may influence technology diffusion in health care. This article empirically examines the relationship between HMO market share and the diffusion of neonatal intensive care units. Higher HMO market share is associated with slower adoption of mid-level units, but not with adoption of the most advanced high-level units. Opposite the common supposition that slowing technology growth will harm patients, results suggest that health outcomes for seriously ill newborns are better in higher-level units and that reduced availability of mid-level units may increase their chance of receiving care in a high-level center, so that slower mid-level growth could have benefitted patients.     

Investigating the significance of insurance and income on health service utilization across generational cohorts

Ensuring access to health services is critical to consumers’ well-being across generational cohorts. Based on pre-disposing characteristics (that is, gender, ethnicity) and financial resources (that is, insurance and income) certain consumers may face barriers to access. In attempt to improve access to health care, this article presents an empirical investigation into how health service utilization can be affected by enabling variables, namely insurance and income. Utilizing proprietary secondary data from a major metropolitan hospital in the United States, the article investigates the following questions: How does insurance and income enable service utilization? How do pre-disposing characteristics of a consumer hinder service access? How does the effect of income and insurance moderate the effect of pre-disposing factors on service utilization? Finally, how do these effects on service utilization vary across generational cohorts? Results indicate that insurance and income may enable access to service, yet this effect is varied among different demographic cohorts and generational groups. The article concludes by offering implications for marketers and policymakers.     

Improving the delivery of clinic care

There has been an increasingly widespread movement toward the delivery of health care in outpatient settings. Hospitals must start to prepare for the shift from inpatient to outpatient services. Reductions in reimbursement and increasing costs will force hospitals to collect and obtain more data on outpatient services. Projecting future demands and assessing current utilization rates are two of the key factors in maintaining stability. This article is a case study of a major urban medical center's outpatient clinic. It includes a summary of observations on the clinic's daily operations and several recommendations for improvement. While the original analysis was highly specific to the actual facility observed, this article has been structured so that it may be applied to other institutions.     

METHODOLOGICAL ASPECTS IN EFFICIENCY EVALUATION OF PUBLIC HOSPITALS

The specific characteristics of the public health care sector prevent the normal working of the market and the trend toward the efficient provision of services. The present study was carried out to offer the Audit Office of the Basque Country and Navarra an objective point of reference from which to measure the efficiency of clinical services. This study consists of an evaluation of the efficient production and utilization of the resources—intermediate services—that hospitals provide to medical staff for carrying out the diagnosis and treatment of patients, together with the efficient use of these intermediate services by the aforementioned medical staff.     

Managed Care and Health Care Utilization: Specification of Bivariate Models Using Copulas

This article studies the effect of managed care on health care utilization compared to traditional fee-for-service plans in private health insurance market. To construct our hypothesis, we build a game-theoretic model to study health care utilization under a two-sided moral hazard: of patients and providers. In econometric modeling, we employ a copula regression to jointly examine individuals’ health plan choice and their utilization of medical care services, because of the endogeneity of insurance choice. The dependence parameter in the copula reflects the relation between the two outcomes, based on which the average treatment effects are further derived. We apply the methodology to a survey data set of the U.S. population and consider three types of curative care and three types of preventive care for the measurement of medical care utilization. We find that managed care is in general associated with higher care utilization. Evidence is also found on the underlying incentives of both patients and medical providers.     

The anticipated real interest rate,capital utilization and the cyclical pattern of real wages

This paper develops a channel through which increases in anticipated real interest rates can be ‘expansionary’ for current aggregate labor demand and current output supply. The key feature of the model is the introduction of a user cost of capital utilization which confronts the firm with the intertemporal problem of the optimal choices of capital utilization and depreciation. The resulting variation in capital utilization and capital services in response to fluctuations in the real rate of interest shifts the marginal product of labor and, thus, the demand for labor at the same time and in the same direction that Lucas-Rapping real interest rate effects operate on labor supply. The complete model places no a priori restrictions on the cyclical pattern of real wages, thus avoiding the countercyclical real wage prediction made by Keynes and various classical writers that is rejected by the data. Estimates of a labor demand schedule for the annual U.S. data reveal a significantly positive real interest rate effect.     

More preventive care, and fewer emergency room visits and prescription drugs--health care utilization in a consumer-driven health plan

Although consumer-driven health plans (CDHPs) have grown dramatically, the question of whether CDHPs have reduced health care costs has not been answered definitively. This article presents what the authors believe to be the first study to analyze a large sample of claims data and to look in detail at different types of utilization among enrollees in a CDHP and those in a traditional comprehensive major medical (CMM) plan. After adjusting for the finding that CDHP enrollees are both younger and healthier than those in CMM plans, the authors found that CDHP enrollees show no consistent or significant utilization differences for measures over which consumers have little control (e.g., inpatient stays); lower utilization for measures over which consumers have greater control (e.g., emergency room visits); and higher utilization of preventive services.     

Onsite concurrent review: impacts on utilization, medical complications and expense

An evaluation of onsite concurrent review over and above the effects of Aetna's precertification program demonstrated reduced utilization and expenses, especially for ancillary services, and no adverse effects on rates of medical complications.     

我国健康保险业的健康管理运行模式构建

健康管理是健康保险转移财务风险、控制成本、解决信息不对称、道德危害等问题的成功策略之一。积极借鉴国外保险业健康管理的成功运行模式(如HMO,PPO,POS等),构建我国健康保险的健康管理运行模式对于我国健康保险业的可持续发展有着重大意义。本文重点研究了健康管理运行模式的重要组成部分:服务人群、服务方式、服务内容、支付机制、成本控制与医疗服务管理机制、利益协调机制、反馈机制等,并探讨了健康管理当前在我国面临的问题,指出必须结合国情构建健康管理运行模式,从而促进我国健康保险业务稳定、持续、健康的发展。     

Medicare--substitute HMOs--reimbursement from other insurance. Care Choices HMO v. Engstrom

The federal statute that permits Medicare-substitute HMOs to seek reimbursement from other insurers does not provide the HMOs with a private federal remedy for reimbursement. It permits Medicare-substitute HMOs to provide in their policies that they are entitled to reimbursement in cases where other insurance, such as the third-party liability insurance of a party responsible for causing an injury, is available. The HMO must sue in state court for its contractual right to reimbursement. It may not sue in federal court under the federal statute that merely allows it to provide for reimbursement in their policies.     

Can you get what you pay for? Pay‐for‐performance and the quality of healthcare providers

Despite the popularity of pay-for-performance (P4P) among health policymakers and private insurers as a tool for improving quality of care, there is little empirical basis for its effectiveness. We use data from published performance reports of physician medical groups contracting with a large network HMO to compare clinical quality before and after the implementation of P4P, relative to a control group. We consider the effect of P4P on both rewarded and unrewarded dimensions of quality. In the end, we fail to find evidence that a large P4P initiative either resulted in major improvement in quality or notable disruption in care.