Marsha Gold

Behind the Curve: A Critical Assessment of How Little is Known about Arrangements between Managed Care Plans and Physicians

Extraordinary growth in managed care arrangements over the past decade has been both widely praised and criticized. Proponents and critics agree that the nature of medical practice is being profoundly altered by this growth, even if they cannot articulate the direction and consequences of this change. We explore the roots of this uncertainty by examining the available evidence on critical features of the arrangements managed care plans currently have with affiliated physicians. Our approach is to review and synthesize the literature in several key substantive areas from a broad range of sources. We found that existing knowledge is dated, derived from a limited subset of plans, inattentive to important structural diferences between plans, and responsive to a very naorow set of issues poorly rflecting the range of medical practice and change introduced by managed care We highlight key questions of interest and the knowledge gaps critical to address so that policy and management decisions can both reflect and be informed on these issues that define the arrangements managed care plans make with physicians and ultimately influence medical practice.

Medicare’s Private Plans: A Report Card On Medicare Advantage

With higher payments and expanded private-plan authority, Medicare Advantage (MA) has caused the market to grow. One in three Medicare beneficiaries with Part D now gets this coverage through MA. Analysis of the sources of and reasons for enrollment growth suggest a troubling report card. Clearly, the Medicare Modernization Act (MMA) has expanded choice and the private-sector role. But it also has added to Medicares complexity and costs and has created potential inequities, without apparent improvements in quality. However the debate ends, a stronger system of performance monitoring and accountability is needed to meet Medicares essential fiduciary requirements and oversight responsibilities.

Markets and Public Programs: Insights from Oregon and Tennessee

Medicaid is the major national program promoting access to care for low-income populations, but the program also is a federal-state partnership. With costs rising and universal access still a remote objective, many states have turned to market-based strategies involving managed care, with the goals of generating savings for the state, improving access for Medicaid beneficiaries, and sometimes expanding coverage to those who were previously uninsured. Yet Medicaid is a complex social insurance system that over time has been used to finance a variety of needs, often using cross-subsidies. In addition, states vary in both the scope of their Medicaid programs and the sophistication of the skills and resources they can bring to bear in shaping them. Understanding how these influence the ability to implement market-based strategies in Medicaid and what the effects of these strategies appear to be is of crucial importance because most states now include some features of this approach in their programs.

Moving research into practice: lessons from the US Agency for Healthcare Research and Quality's IDSRN program

BackgroundThe U.S. Agency for Healthcare Research and Qualitys (AHRQ) Integrated Delivery Systems Research Network (IDSRN) program was established to foster public-private collaboration between health services researchers and health care delivery systems. Its broad goal was to link researchers and delivery systems to encourage implementation of research into practice. We evaluated the program to address two primary questions: 1) How successful was IDSRN in generating research findings that could be applied in practice? and 2) What factors facilitate or impede such success?MethodsWe conducted in-person and telephone interviews with AHRQ staff and nine IDSRN partner organizations and their collaborators, reviewed program documents, analyzed projects funded through the program, and developed case studies of four IDSRN projects judged promising in supporting research implementation.ResultsParticipants reported that the IDSRN structure was valuable in creating closer ties between researchers and participating health systems. Of the 50 completed projects studied, 30 had an operational effect or use. Some kinds of projects were more successful than others in influencing operations. If certain conditions were met, a variety of partnership models successfully supported implementation. An internal champion was necessary for partnerships involving researchers based outside the delivery system. Case studies identified several factors important to success: responsiveness of project work to delivery system needs, ongoing funding to support multiple project phases, and development of applied products or tools that helped users see their operational relevance. Factors limiting success included limited project funding, competing demands on potential research users, and failure to reach the appropriate audience.ConclusionForging stronger partnerships between researchers and delivery systems has the potential to make research more relevant to users, but these benefits require clear goals and appropriate targeting of resources. Trade-offs are inevitable. The health services research community can best consider such trade-offs and set priorities if there is more dialogue to identify areas and approaches where such partnerships may have the most promise. Though it has unique features, the IDSRN experience is relevant to research implementation in diverse settings.

ISO Quick Fix, Free Lunch, and Share of Pie

The “managed care backlash” is as inevitable as the forces that encouraged the rapid development of managed care in the 1990s. What is less certain is how the forces unleashed by the backlash will unfold and what they will mean for the future way the health care system in the United States functions. In this commentary, I argue that the managed care backlash reflects a prototypical American response that could have been anticipated with the demise of Clinton health reform in the early 1990s. Absent legislated reform, a competitive solution based on managed care was uniquely fitting for the United States’s pluralistic, mixed public-private system of finance and delivery. Purchasers turned increasingly to the market and managed care as a vehicle for cost control. In the absence of national policy, payers sought to achieve their own ends, with little formal infrastructure in which to address collective and public goods (such as the cost of care for the uninsured and those less able to strike a hard bargain). The movement toward managed care reinforced already existing changes in provider practice and set in motion a series of interrelated “shocks” that generated many of the preconditions for a managed care backlash. Further fueling the backlash were the systematic reactions from the shift to managed care using a competitive model. Responding to the business opportunities the shift created, “health industry” broadly speaking, engaged in a series of mergers and reshuffling of ownership and affiliations that reduced public goodwill and loyalty. “Mass media,” aided by the growing ease of nationwide communication, highlighted

Quality Improvement in Medicaid Managed Care: Experience of the Best Clinical and Administrative Practices Initiative

BACKGROUND The Best Clinical and Administrative Practices (BCAP) initiative is part of the Medicaid Managed Care Program (MMCP) operated by the Center for Health Care Strategies. Work groups of 10-12 plans addressed quality of care in designated areas. METHODS AND INFORMATION SOURCES The assessment of BCAP was part of a larger MMCP program evaluation funded by the Robert Wood Johnson Foundation. Case studies were developed for four BCAPs that focused respectively on improving birth outcomes, preventive care for children, asthma care, and care for adults with chronic illnesses or disabilities. They were based on document review and semistructured interviews. Medicaid managed care plans nationwide were also surveyed. FINDINGS BCAP participants were overwhelmingly risk-based managed care plans whose enrollment was dominated by Medicaid. Participants said BCAP helped them enhance the way they approach quality improvement. As a result of work group participation, most plans made changes in their delivery of care, and more than half sustained and continued to build on these changes after the work group ended. DISCUSSION BCAP participation helped Medicaid plans change the way they think about quality improvement and take sustainable steps to improve quality; the ultimate impact may be stronger once plans become more sophisticated users of such techniques.

Design and Feasibility of a National Medicaid Access Survey with State-Specific Estimates

This article presents the results ofa study to design and assess the feasibility of conducting a national Medicaid Access Survey to generate timely, state-specific estimates of access to care for Medicaid enrollees. State-specific data on Medicaid access is especially relevant because state programs and environments vary considerably and are changing rapidly in ways that could influence access. We analyze (1) basic survey design parameters and instrument content, (2) alternative sampling approaches and their feasibility, (3) pilot test results, (4) the feasibility of using existing national surveys to generate comparison estimates for state-based surveys, and (5) estimates of the required sample size and costs for such a national Medicaid Access Survey. We conclude that a survey generating timely, state-speafic estimates of Medicaid access is both feasible and affordable if attention is paid to key design challenges while keeping objectives and design simple.

Consumer Engagement in Health IT: Distinguishing Rhetoric from Reality.

Rationale: Policymakers want health information technology (health IT) to support consumer engagement to help achieve national health goals. In this paper, we review the evidence to compare the rhetoric with the reality of current practice. Current Reality and Barriers: Our environmental scan shows that consumer demand exists for electronic access to personal health information, but that technical and system or political barriers still limit the value of the available information and its potential benefits. Conclusions and Policy Implications: There is a gap between current reality and the goals for consumer engagement. Actions that may help bridge this gap include: (1) resolving technical barriers to health information exchange (HIE); (2) developing more consumer-centric design and functionality; (3) reinforcing incentives that attract provider support by showing that consumer engagement is in their interest; and (4) building a stronger empirical case to convince decision makers that consumer engagement will lead to better care, improved health outcomes, and lower costs.

Critical Challenges in Making Health Services Research Relevant to Decision Makers

In this Commentary, the author discusses how the environment in which our research is received and used creates opportunities but also challenges to relevance that warrant greater consideration and active discussion within the health services research community.

Oil and water? Lessons from Maryland's effrort to protect safety net providers in moving to Medicaid managed care

Studies have highlighted the tensions that can arise between Medicaid managed care organizations and safety net providers. This article seeks to identify what other states can learn from Marylands effort to include protections for safety net providers in its Medicaid managed care program—HealthChoice. Under HealthChoice, traditional provider systems can sponsor managed care organizations, historical providers are assured of having a role, patients can self-refer and have open access to certain public health providers, and capitation rates are risk adjusted through the use of adjusted clinical groups and claims data. The article is based on a week-long site visit to Maryland in fall 1998 that was one part of a seven-state study. Marylands experience suggests that states have much to gain in the way of “good” public policy by considering the impact of their Medicaid managed care programs on the safety net, but states should not underestimate the challenges involved in balancing the need to protect the safety net with the need to contain costs and minimize the administrative burden on providers. No amount of protection can compensate for a poorly designed or implemented program. As the health care environment continues to change, so may the need for and the types of protections change. It also may be most difficult to guarantee adequate protections to those who need it most—among relatively financially insecure providers that have a limited management infrastructure and that depend heavily on Medicaid and the state for funds to care for the uninsured.