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Medicaid capitation rates: methodological shortcomings and recommended solutions. 医疗补助的人均费率:方法上的缺陷和建议的解决方案。
GHAA journal Pub Date : 1988-01-01
W P Segodnia
{"title":"Medicaid capitation rates: methodological shortcomings and recommended solutions.","authors":"W P Segodnia","doi":"","DOIUrl":"","url":null,"abstract":"<p><p>At both the federal and state level, managed care programs are considered one of the key solutions to the problem of containing costs in public sector health care programs, such as Medicaid; however, reimbursement issues need to be resolved before managed care programs can fully embrace public sector programs. Federal regulations require state Medicaid agencies to establish capitation rates that use fully documented actuarial methods that do not exceed the equivalent cost to the state for providing services to a like population. State agencies must also assure managed care programs that timely and reliable data is used, a sound actuarial method is employed, and the capitation rate is fair and equitable. Contractor confidence in a rate methodology will facilitate their participation in Medicaid. Reimbursement in managed care systems is usually based on some discount of the fee-for-service (FFS) equivalent capitation. Yet, state agencies differ in their ability to derive an accurate FFS capitation. This paper explores many of the methodological shortcomings common in using the FFS approach and offers some policy and technical solutions.</p>","PeriodicalId":79893,"journal":{"name":"GHAA journal","volume":"9 2","pages":"83-95"},"PeriodicalIF":0.0,"publicationDate":"1988-01-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"21175786","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
引用次数: 0
A practical guide to HMO market entry strategies for physicians and physician groups. 为医生和医生团体的HMO市场进入策略的实用指南。
GHAA journal Pub Date : 1988-01-01
B S Scheur, P J Martin
{"title":"A practical guide to HMO market entry strategies for physicians and physician groups.","authors":"B S Scheur,&nbsp;P J Martin","doi":"","DOIUrl":"","url":null,"abstract":"","PeriodicalId":79893,"journal":{"name":"GHAA journal","volume":"9 1","pages":"55-68"},"PeriodicalIF":0.0,"publicationDate":"1988-01-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"21175753","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
引用次数: 0
Enrollment in the TEFRA risk program: InterStudy's data differ markedly from HCFA's. TEFRA风险项目的入组:InterStudy的数据与HCFA的数据明显不同。
GHAA journal Pub Date : 1988-01-01
B M Simone, R L Lichtenstein, J Adams-Watson
{"title":"Enrollment in the TEFRA risk program: InterStudy's data differ markedly from HCFA's.","authors":"B M Simone,&nbsp;R L Lichtenstein,&nbsp;J Adams-Watson","doi":"","DOIUrl":"","url":null,"abstract":"","PeriodicalId":79893,"journal":{"name":"GHAA journal","volume":"9 2","pages":"4-13"},"PeriodicalIF":0.0,"publicationDate":"1988-01-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"21175784","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
引用次数: 0
Disenrollment patterns in Medicare HMOs: a preliminary analysis. 医疗保险hmo的退出模式:初步分析。
GHAA journal Pub Date : 1988-01-01
A M Tucker, K Langwell
{"title":"Disenrollment patterns in Medicare HMOs: a preliminary analysis.","authors":"A M Tucker,&nbsp;K Langwell","doi":"","DOIUrl":"","url":null,"abstract":"<p><p>This paper examines disenrollment patterns of 17 Medicare Competition Demonstration HMOs during 1984. Characteristics of HMO disenrollees for a sample of Medicare beneficiaries from two surveys conducted in early 1985 and 1986 are also examined. These data provide a preliminary, descriptive analysis of the nature and the implications of Medicare HMO disenrollment.</p>","PeriodicalId":79893,"journal":{"name":"GHAA journal","volume":"9 1","pages":"22-41"},"PeriodicalIF":0.0,"publicationDate":"1988-01-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"21175749","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
引用次数: 0
Marketing in the HMO industry: an analysis of spending patterns and enrollment growth results. HMO行业的市场营销:支出模式和注册增长结果的分析。
GHAA journal Pub Date : 1988-01-01
J J Menges
{"title":"Marketing in the HMO industry: an analysis of spending patterns and enrollment growth results.","authors":"J J Menges","doi":"","DOIUrl":"","url":null,"abstract":"<p><p>The purpose of this paper is to assess the level of marketing spending in the HMO industry and the enrollment growth HMOs have achieved in return for their marketing dollars. This study identifies industry norms that are designed to assist HMOs in the evaluation of their marketing performance. The study is based on data from 1985 to 1986 covering approximately half the HMOs in the country and comprising a substantial proportion of industry-wide enrollment (Table 1). The analyses are designed to allow operational HMOs to compare their marketing efforts, enrollment growth, and marketing costs per new member with industry norms within similar age, model type, enrollment level, and geographic categories. The marketing expenses provided by each HMO are an aggregate figure including sales staff salaries, benefits and commissions, advertising, costs for the production and printing of marketing materials, and all other expenses directly related to the marketing effort. Components of the aggregate marketing expenses, such as the amount spent on advertising versus sales staff compensation, were not available.</p>","PeriodicalId":79893,"journal":{"name":"GHAA journal","volume":"9 2","pages":"20-47"},"PeriodicalIF":0.0,"publicationDate":"1988-01-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"21183841","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
引用次数: 0
Approaches to primary care. Physician capitation. 初级保健方法。医生均摊。
GHAA journal Pub Date : 1988-01-01
N S Fleming, D G Fleming
{"title":"Approaches to primary care. Physician capitation.","authors":"N S Fleming,&nbsp;D G Fleming","doi":"","DOIUrl":"","url":null,"abstract":"<p><p>The first author, as a consultant to the Office of Prepaid Health Care, reviewed the financial status of nine IPAs for federal qualification in 1987. He found little to suggest any methodology being used for constructing primary care physician (PCP) capitation reimbursement systems. This article draws upon statistical theory and presents hypothetical examples to structure better financial arrangements based on five criteria: stop-loss reinsurance deductible levels, capitation of services related to physician practice, minimum panel size (number of patients) for capitation, stratified capitation, and inclusion of all PCPs in the capitation arrangement.</p>","PeriodicalId":79893,"journal":{"name":"GHAA journal","volume":"9 1","pages":"4-13"},"PeriodicalIF":0.0,"publicationDate":"1988-01-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"21181462","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
引用次数: 0
Community rating by class as a method of adjusting community rated employer group capitation premiums. 按类别进行社区评级，作为调整社区评级雇主集团总保费的方法。
GHAA journal Pub Date : 1988-01-01
D G Cave, S O Schweitzer, P A Lachenbruch
{"title":"Community rating by class as a method of adjusting community rated employer group capitation premiums.","authors":"D G Cave,&nbsp;S O Schweitzer,&nbsp;P A Lachenbruch","doi":"","DOIUrl":"","url":null,"abstract":"","PeriodicalId":79893,"journal":{"name":"GHAA journal","volume":"9 1","pages":"80-96"},"PeriodicalIF":0.0,"publicationDate":"1988-01-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"21163740","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
引用次数: 0
To hospitalize or not to hospitalize: HMO versus fee-for-service. 住院或不住院:HMO与收费服务。
GHAA journal Pub Date : 1988-01-01
I Strumwasser, N V Paranjpe, J McGinnis, D L Ronis
{"title":"To hospitalize or not to hospitalize: HMO versus fee-for-service.","authors":"I Strumwasser,&nbsp;N V Paranjpe,&nbsp;J McGinnis,&nbsp;D L Ronis","doi":"","DOIUrl":"","url":null,"abstract":"","PeriodicalId":79893,"journal":{"name":"GHAA journal","volume":"9 1","pages":"42-54"},"PeriodicalIF":0.0,"publicationDate":"1988-01-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"21163737","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
引用次数: 0
Experience rating and administrative services only arrangements for HMOs. 医疗服务机构的经验评级及行政服务安排。
GHAA journal Pub Date : 1988-01-01
R P Herman, D E Freier
{"title":"Experience rating and administrative services only arrangements for HMOs.","authors":"R P Herman,&nbsp;D E Freier","doi":"","DOIUrl":"","url":null,"abstract":"","PeriodicalId":79893,"journal":{"name":"GHAA journal","volume":"9 1","pages":"69-79"},"PeriodicalIF":0.0,"publicationDate":"1988-01-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"21163739","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
引用次数: 0
Medicare patients and alternatives to the acute care hospital. 医疗保险患者和替代急性护理医院。
GHAA journal Pub Date : 1988-01-01
B E Lewis, C Hussey
{"title":"Medicare patients and alternatives to the acute care hospital.","authors":"B E Lewis,&nbsp;C Hussey","doi":"","DOIUrl":"","url":null,"abstract":"<p><p>There are many instances where hospitalized elderly patients no longer need intensive hospital care but are not ready to be discharged. One solution to this dilemma is the use of a skilled nursing facility (SNF) or some type of step-down bed, where patients can continue to receive managed care at a less intense and costly level. A major concern with using step-down beds is that while costs may be controlled, quality of care may suffer and patient outcomes may be jeopardized. From an efficiency perspective, the step-down bed can provide an excellent alternative to hospital care for the less acutely-ill patient. For alternative managed care environments to be satisfactorily received by patients and physicians, however, they must produce outcomes equal or better than those in the hospital. Some patients and diagnoses are more appropriate than others for treatment in alternative managed care environments. The judgement of appropriateness must take into account patient and physician satisfaction with the efficiency and effectiveness of the care. This paper describes how the Fallon Community Health Plan, Worcester, Mass., which regularly uses a step-down facility for patient care, assessed outcomes in terms of efficiency and effectiveness. An overview of this alternative managed care facility and its relationship to the HMO is discussed below. Several studies examining outcomes and patient and physician satisfaction are presented. Finally, the ways in which these studies represent a merger of quality assurance (QA) and utilization review (UR) methodologies are discussed.</p>","PeriodicalId":79893,"journal":{"name":"GHAA journal","volume":"9 2","pages":"70-82"},"PeriodicalIF":0.0,"publicationDate":"1988-01-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"21175785","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
引用次数: 0
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