Robert E. Hurley

A National Survey of the arrangements managed-care plans make with physicians

BACKGROUNDnDespite the growth of managed care in the United States, there is little information about the arrangements managed-care plans make with physicians.nnnMETHODSnIn 1994 we surveyed by telephone 138 managed-care plans that were selected from 20 metropolitan areas nationwide. Of the 108 plans that responded, 29 were group-model or staff-model health maintenance organizations (HMOs), 50 were network or independent-practice-association (IPA) HMOs, and 29 were preferred-provider organizations (PPOs).nnnRESULTSnRespondents from all three types of plan said they emphasized careful selection of physicians, although the group or staff HMOs tended to have more demanding requirements, such as board certification or eligibility. Sixty-one percent of the plans responded that physicians previous patterns of costs or utilization of resources had little influence on their selection; 26 percent said these factors had a moderate influence; and 13 percent said they had a large influence. Some risk sharing with physicians was typical in the HMOs but rare in the PPOs. Fifty-six percent of the network or IPA HMOs used capitation as the predominant method of paying primary care physicians, as compared with 34 percent of the group or staff HMOs and 7 percent of the PPOs. More than half the HMOs reported adjusting payments according to utilization or cost patterns, patient complaints, and measures of the quality of care. Ninety-two percent of the network or IPA HMOs and 61 percent of the group or staff HMOs required their patients to select a primary care physician, who was responsible for most referrals to specialists. About three quarters of the HMOs and 31 percent of the PPOs reported using studies of the outcomes of medical care as part of their quality-improvement programs.nnnCONCLUSIONSnManaged-care plans, particularly HMOs, have complex systems for selecting, paying, and monitoring their physicians. Hybrid forms are common, and the differences between group or staff HMOs and network or IPA HMOs are less extensive than is commonly assumed.

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.

An Empty Toolbox? Changes in Health Plans’ Approaches for Managing Costs and Care

OBJECTIVEnTo examine how health plans have changed their approaches for managing costs and utilization in the wake of the recent backlash against managed care.nnnDATA SOURCES/STUDY SETTINGnSemistructured interviews with health plan executives, employers, providers, and other health care decision makers in 12 metropolitan areas that were randomly selected to be nationally representative of communities with more than 200,000 residents. Longitudinal data were collected as part of the Community Tracking Study during three rounds of site visits in 1996-1997, 1998-1999, and 2000-2001.nnnSTUDY DESIGNnInterviews probed about changes in the design and operation of health insurance products--including provider contracting and network development, benefit packages, and utilization management processes--and about the rationale and perceived impact of these changes.nnnDATA COLLECTION/EXTRACTION METHODSnData from more than 850 interviews were coded, extracted, and analyzed using computerized text analysis software.nnnPRINCIPAL FINDINGSnHealth plans have begun to scale back or abandon their use of selected managed care tools in most communities, with selective contracting and risk contracting practices fading most rapidly and completely. In turn, plans increasingly have sought cost savings by shifting costs to consumers. Some plans have begun to experiment with new provider networks, payment systems, and referral practices designed to lower costs and improve service delivery.nnnCONCLUSIONSnThese changes promise to lighten administrative and financial burdens for physicians and hospitals, but they also threaten to increase consumers financial burdens.

Specialty differences in the treatment of asthma

This is one of a series of occasional articles reflecting the opinions of respected authors or groups in areas of considerable interest and debate. They have not been peer reviewed in the usual manner and have not been edited by the JOURNAL. This particular article describes a study commissioned b) the Joint Council of Allergy and Immunology. It is hoped that the Rostrum articles will spark interest and discussion.

Variations in inpatient mortality among hospitals in different system types, 1995 to 2000.

Background:Relatively few studies focused on the impact of system formation and hospital merger on quality, and these studies reported typically little or no quality effect. Objective:To study associations among 5 main types of health systems–centralized, centralized physician/insurance, moderately centralized, decentralized, and independent–and inpatient mortality from acute myocardial infarction (AMI), congestive heart failure, stroke, and pneumonia. Data and Methods:Panel data (1995–2000) were assembled from 11 states and multiple sources: Agency for Healthcare Research and Quality State Inpatient Database, American Hospital Association Annual Surveys, Area Resource File, HMO InterStudy, and the Centers for Medicare and Medicaid Services. We applied a panel study design with fixed effects models using information on variation within hospitals. Results:We found that centralized health systems are associated with lower AMI, congestive heart failure, and pneumonia mortality. Independent hospital systems had better AMI quality outcomes than centralized physician/insurance and moderately centralized health systems. We found no difference in inpatient mortality among system types for the stroke outcome. Thus, for certain types of clinical service lines and patients, hospital system type matters. Research that focuses only on system membership may mask the impact of system type on the quality of care.

A typology of Medicaid managed care.

This article presents a typology for use in classifying and interpreting the findings of the growing empirical literature on managed care initiatives in the Medicaid program. Six key program attributes are identified for use in examining similarities and differences among these programs. Several alternative arrangements for each attribute are described from among the more than 60 different programs attempted. The typology is illustrated with five specific program designs, and selected empirical results from them are used to demonstrate how the typology can be employed.

Early experiences with consumer engagement initiatives to improve chronic care.

Engaging consumers to be more active participants in their health and health care is an appealing strategy for reforming the U.S. health care system, but little is known about how to mount and sustain communitywide consumer engagement initiatives. The Robert Wood Johnson Foundation launched a program in 2006 in fourteen communities to align forces around improving quality and efficiency by promoting public reporting and expanding the involvement of consumers in all facets of their care. These multistakeholder organizations provide an early glimpse into the opportunities and challenges that lie ahead as policymakers attempt to integrate consumers more completely in their reform strategies.

Challenges of Capacity Building in Multisector Community Health Alliances

Capacity building is often described as fundamental to the success of health alliances, yet there are few evaluations that provide alliances with clear guidance on the challenges related to capacity building. This article attempts to identify potential challenges of capacity building in multistakeholder health alliances. The study uses a multiple case study design to identify potential challenges and trade-offs associated with capacity building in four community health alliances in the United States. Multiple challenges were found to be common across the four alliances, including specifying appropriate governance structures and decision-making frameworks, aligning stakeholder interests with the vision of the alliance, balancing short-term objectives with long-term goals, and securing resources to sustain the effort without compromising it. These challenges often involved trade-offs and choices that alliances need to prepare for if they are to approach capacity building in a planful rather than a reactive manner.

Organizational ecology and health services research: new answers for old and new questions.

*Instructor, Department of Health Planning and Administration, Pennsylvania State University, University Park, PA. tProfessor, Department of Health Policy and Administration, School of Public Health, University of North Carolina-Chapel Hill, NC. Health service organizations are under siege. Dramatic changes are occurring in existing organizations, and new organizational forms are emerging at an accelerating rate. Existing organizational theory

Academic health centers and the changing health care market.

Academic health centers (AHCs) have supported their mission of patient care, education, and research through a complex system of cross-subsidies, many of which originate from patient care activities. The proliferation of managed care and health care reform initiatives, however, are threatening this traditional method of financing. This article begins by describing the financing of AHCs and the web of cross-subsidization that occurs at these institutions. The article then reviews the literature on the threats that AHCs are facing in the current health care market, how these threats are affecting their missionrelated activities, and how they are responding to and managing these threats. The article concludes with a summary of our current understanding of AHCs and presents a research agenda of issues in need of further study.