Stephen M. Davidson

Toward an Effective Strategy for the Diffusion and Use of Clinical Information Systems

The full impact of IT in health care has not been realized because of the failure to recognize that (1) the path from availability of applications to the anticipated benefits passes through a series of steps; and (2) progress can be stopped at any one of those steps. As a result, strategies for diffusion, adoption, and use have been incomplete and have produced disappointing results. In this paper, we present a comprehensive framework for identifying factors that affect the spread, use, and effects of IT in the U.S. health care sector. The framework can be used by researchers to focus their efforts on unanswered questions, by practitioners considering IT adoption, and by policymakers searching for ways to spread IT throughout the system.

Physician Participation in Medicaid: Background and Issues

Most Americans gain entry into the medical care system through office-based primary care physicians. The Medicaid program was created in 1965 in part to increase the access of low-income people to medical services in that mainstream. But, over the years, office-based physicians have reduced their treatment of Medicaid patients, and many have withdrawn from the program altogether. The result is not only that the original programmatic goal has not been fully achieved, but also that the costs of the program are higher than they would be otherwise. In this article, the importance of Medicaid participation by office-based primary care physicians is described, and a number of obstacles to their participation are identified. The obstacles include state policies regarding eligibility, coverage, and provider compensation. The article recommends actions pertaining to these policies that might increase participation.

Remaking medicaid : managed care for the public good

THE CONTEXT Understanding the Context for Medicaid Managed Care - Stephen M. Davidson & Stephen A. Somers Have We Overdosed on a Panacea? Reflections on the Evolution of Medicaid Managed Care - Robert E. Hurley Impact of the New Federalism on Medicaid - John Holahan, et al Commentary: A Medicaid Directors Point of View - Bruce Bullen THE PROMISE Risky Business: Medical Groups and Full-Risk Capitation in California - Lawrence P. Casalino Medicaid Managed Care and Disabled Populations - Robert J. Master Commentary: A Providers View - Richard J. Baron LESSONS FROM THE FIELD The Arizona Health Care Cost Containment System - Nelda McCall Medicaid Managed Care Programs in Hawaii, Oklahoma, Rhode Island, and Tennesse - Leighton Ku, et al ISSUES AND CHALLENGES What the States Can Expect from Medicaid Managed Care and Why - Stephen M. Davidson Negotiating the New Health System: A Nationwide Analysis of Medicaid Managed Care Contracts - Sara Rosenbaum Health-Based Payment and Other Challenges of Medicaid Managed Care - Richard Kroncik & Tony Dreyfus Special Plans for Special Persons: The Elusive Pursuit of Customized Managed Care - Robert E. Hurley & Debra A. Draper MONITORING THE PERFORMANCE Encounter Data and Medicaid Managed Care: Reasonable Expectations for Information in the New World - Kathe P. Fox, et al Quality Management in Medicaid Managed Care - Arnold M. Epstein Making It Work for the Consumer - Stephanie Davis & Richard G. Potter Ambulartory Care Providers and the Transition to Medicaid Managed Care in New York City - Joel C. Cantor, et al CONCLUSION Looking Back, Looking Ahead - Stephen M. Davidson & Stephen A. Somers.

Medicaid Myths: Trends in Medicaid Expenditures and the Prospects for Reform

Medicaid expenditures, which had reached more than +32 billion by 1981, have grown substantially throughout the programs history. As a result, the conventional wisdom is that Medicaid expenditures represent a significant public-policy problem. Using other measures, however, it can be shown that the program is much less of a problem than it appears to be. By 1981, spending for Medicaid represented only 12.7 percent of total state spending and had contributed only 14.2 percent to the overall growth in state expenditures since 1965. Moreover, considering only the funds which states raise from in-state sources, the median share of state budgets accounted for by Medicaid was just 5.6 percent, and only 7 states spent as much as 9 percent of their own money on the program. These figures suggest that the marginal reductions in Medicaid expenditures which would result from typical program changes are likely to be so small that rational state officials might be unwilling to incur the political opposition of powerful provider groups or the resistance of large state bureaucracies by proposing substantial reforms. The major exceptions are the few states with very large programs where even small proportional savings would amount to millions of dollars. We conclude that, given its present federal-state form and the current distribution of expenditures, it is unlikely that major reforms will be enacted because the stakes are too small for most states and the federal interest is too diffused.

Medicaid: taking stock.

In the last few years, Medicaid has attracted more than casual attention, one reflection of which is the fact that JHPPL has published five papers on the program in its last few issues. This paper, a sixth, takes a broader view of the program than is typically the case. After a critique of the five recent articles, I discuss several questions raised by them and reach the following conclusions: First, the states do not invest enough in producing program data suitable for policy analysis and research. One lesson: Better data and analysis can help the states to avoid expensive mistakes. Second, those policy analyses that have been offered fail to give sufficient attention to the political dimension of policy. That is one reason why policy choices produce unexpected effects. Third, since Medicaid is a relatively small player in the vast medical care market, incentives adopted by Medicaid officials throughout the country rarely have the desired effects. Finally, as long as Medicaid remains the principal mechanism to provide access to health care for the poor, it must be made as efficient and effective as possible. Yet, for both political and economic reasons, Medicaid can never be what its original planners had hoped, the vehicle for providing the poor with reliable access to mainstream medical care.

The physician-manager alliance : building the healthy health care organization

The High Stakes of Change: The Need for Physician-Manager Alliances. Our Growing Dependence on Organizations. The Health Care Customer in the New Marketplace. Physicians and Managers: The Search for Common Ground. Moving Toward the Health Care Organization: Identifying the Critical Changes. Measuring Effiiciency, Effectiveness and Satisfaction. Understanding the Physician-Manager Relationship: Five Perspectives. An Open Systems View: A Realistic Framework for the Health Care Organization. The Problem-Solving Approach: Creating Collaboration.

Variations in State Medicaid Programs

Many federal laws permit the states considerable latitude in determining the important characteristics of programs created under them. Yet, frequently, this aspect is overlooked in the analyses of differences in state-level programs. The purpose of this paper is to present a measure to aid in the analysis of one such program, Medicaid, and to illustrate some of the ways it can be useful. The Medicaid Program Index (MPI) differentiates among state Medicaid programs according to four important characteristics: inclusion of the medically indigent, the optional services covered, limitations on the provision of the basic services, and arrangements for paying providers. Data are presented to show that, in fact, the states do vary considerably on these factors, which can be analyzed in the aggregate (i.e., as the MPI) or separately. In addition, several uses for the MPI are discussed. They include: (1) identifying variations in state programs; (2) accounting for those differences by comparing them to promising explanatory variables; (3) identifying trends in program characteristics over time: and (4) developing hypotheses to account for those trends. Finally, it was suggested that similar measures can be developed to facilitate analyses of other federal/state programs.

Can Public Policy Fix What Ails Managed Care

Whether problems associated with the rush to managed care are subject to a public policy remedy depends on the answers to the following questions: First, what are the problems to be solved and are they both systemic and serious enough to require such a solution? If so, could a public policy remedy be crafted that, if adopted and implemented, would in fact solve them? Then, if the answer to the last question is yes, can a sufficiently strong version emerge from the political process and actually be adopted and implemented? Robert Blendon et al. (1998) have argued (1) that there is no evidence that medical care has deteriorated under managed care and (2) that the backlash is largely the fear people have about their own future ability to obtain care. They already feel constrained in their use of the system and they know the horror stories that receive so much media attention. As a result, many are afraid they will not be able to get the services they need when they are sick. Blendon and his colleagues may, indeed, be correct. Certainly, there is little persuasive evidence to demonstrate that, in the aggregate, care has deteriorated because of managed care. Yet, real suffering has occurred, and some of it is attributable to bad decisions made by officials of managed care organizations (MCOs). But errors and insensitivity to patients were part of the indemnity landscape as well, and in spite of the publicity, there is no evidence that either has increased substantially. As analysts who like to be guided by data, we might therefore be tempted to say that proposals for “reform” are premature because large-

Heeding The Politics Of Reform

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