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Claims payable management is vital due to its large influence. The report, which examines the issues of the claims payable management by health maintenance organizations (HMOs) in US from 1985-2001, is presented.

The observations, which are from cohort model regarding the economic effect of handling the termination of smoking in a theoretical managed care organization (MCO), are presented.

In recent years, overall AIDS mortality in the U.S. has declined, but declines have not been consistent across all populations. In particular, AIDS mortality rates among minorities and injection drug […]

The study using health outcomes after the treatment for Acute Myocardial Infarction (AMI) shows two types of financial pressures, fiscal pressure from the Prospective Payment System (PPS) for inpatient care, and changes in Health Maintenance Organization (HMO) penetration at the country level.

An analysis of medical treatment cost differences between indemnity health insurance plans and HMO plans is offered. Additional information on cost differences in treating eight major medical conditions by both plans is included.

Health maintenance organizations(HMOs) participation in Medicare+Choice program is decreasing contrary to expectations. Significant changes are required in Medicare fee-for-service and HMO payment policies to maintain the current size of the Medicare HMO market as well as for the growth of the same.

Data showing comparison of all managed care plans available on Medicare's internet website and on a toll free hotline, as mandated by the US Congress may not be influencing the choice between the original Medicare and a (HMO) but it certainly affects the choice of the HMO. This is ascertained by a laboratory experiment using a convenience sample of 225 Medicare beneficiaries.

In 1996, the eight-million member Kaiser Permanente HMO adopted a vision statement that said by 2005 it would expand its services to include home- and community-based services for its members with disabilities. It funded a 3-year, 32-site demonstration that showed that it was feasible to link HMO services with existing home- and community-based (HCB) services and that members appreciated the improved coordination and access. This private-sector project showed that devolution can produce innovative and feasible models of care, but it also showed that without federal financial and regulatory support, such models are unlikely to take hold if they are focused on 'unprofitable' populations, for example, those who are chronically ill, poor, and/or disabled. [Article copies available for a fee from The Haworth Document Delivery Service: 1-800-HAWORTH. E-mail address: Website: KEYWORDS. Managed care, home care, care management, integration

An analysis of the impact of the managed care insurance products on consumers' access to health care, the use of primary and specialty medical care and consumer assessments of health care is offered. Additional information on insurance product types is included.

An analysis of physician services provided to HMO patients using the data from the 1993-1996 National Ambulatory Medical Care Survey is offered. Additional information on models analyzing physician services in a managed care environment is included.

Information on General Motors Corp's use of a health plan report card to analyze employees' health plan enrollment choices during 1996-1997 is offered. Additional information on how health plan performance ratings and out-of-pocket contributions influence employees' choices of enrolling in health plans is included.

Byline: M. Sklansky (1), R. Shaughnessy (1), V. Lucas (1), I. Kashani (1), A. Rothman (1) Keywords: Key words: Fetal echocardiography -- Congenital heart disease -- Termination of pregnancy Abstract: Fetal echocardiographic findings, and decisions to continue or to terminate affected pregnancies, may differ between university (UNIV) and health maintenance organization (HMO) settings. The aim of this study was to review the fetal echocardiographic experience at a combined university/health maintenance organization program over a 4-year period. Imaging and counseling for affected pregnancies were provided by the same, single investigator at both sites. Out of a total of 1382 studies (940 UNIV, 442 HMO), 127 abnormals were identified (94 UNIV, 33 HMO). Among the 127 pregnancies with fetal heart disease, 24 (19%) underwent elective termination, 16% at UNIV and 27% at HMO (p= 0.2). Mean gestational age at the time of diagnosis was 25.2 weeks at UNIV compared with 22.3 weeks at HMO (p= 0.002). At UNIV, only 51% of diagnoses were made before 24 weeks compared with 79% at HMO (p= 0.003). Screening fetal sonograms, performed between 18 and 20 weeks on every pregnancy at HMO but not at UNIV, enabled earlier detection of congenital heart disease (CHD) and allowed more women with severely affected pregnancies the option to terminate. In both settings, indications with the highest yields for CHD included a right-sided stomach, abnormal four-chamber view, sustained bradycardia, abnormal fetal karyotype, fetal omphalocele, and maternal indomethacin. An echogenic reflector was identified in 86 pregnancies (7%) and did not represent a risk factor for CHD. No major differences in CHD were found between UNIV and HMO. In summary, this study found a significantly earlier diagnosis of CHD at HMO than at UNIV. This discrepancy between programs may explain, at least in part, the trend toward a higher frequency of decisions to terminate affected pregnancies at HMO than at UNIV, despite similar fetal findings. Author Affiliation: (1) Division of Pediatric Cardiology, Department of Pediatrics, University of California, San Diego, 200 West Arbor Drive, San Diego, CA 92103-8445, USA, US

Not all ACOs are created equal, according to Linda F. Delo, DO, owner of Delo Medical Associates, a family practice in Port St. Lucie, Fla. She says that her initial [...]

The methodology used to analyze the effect of health maintenance organizations on HMO and non-HMO enrollees' access to health care is offered. Additional information on health care models analyzing the use of health care services and consumer assessments of health care quality is also included.

The effect of health maintenance organizations on HMO and non-HMO enrollees' access to health care is analyzed. Additional information on various factors impacting access to health care is also included.

HMOs' effect on access to health care of HMO and non-HMO enrollees is analyzed. Additional information on access to primary care and use of costly health care is also included.

The effects of health maintenance organizations on evaluation of health care services by patients are analyzed. Additional information on mathematical models use to analyze consumers' assessment of health care services is also included.

The effects of health maintenance organizations on patients' use of hospital care, preventive health care, ambulatory care and surgery are analyzed. Additional information on impact of HMOs on specialized health care services is also included.

A general analysis of services offered by health maintenance organizations is offered. Additional information on managed health care system is also included.

Health maintenance organizations employ a separate committee that evaluates the medical benefits promised by innovative medical technologies. The committee uses a scientific approach in evaluating these technologies. Its credibility and power rests upon its open and rigorous approval process. Blue Shield of California and the Blue Cross Blue Shield Assn have both installed technology-assessment committees which aid in approving new technologies and subsequently including them in their coverage., Health plans are notoriously reluctant to sanction expensive new therapies. That's why this payer's pioneering approach to technology assessment may surprise you. Health insurance premiums are ticking up again, and [...]

A full-professional risk capitation (FRC) contract provides all professional services to a health maintenance organization enrollee in return for a fixed monthly payment. However, there are several guidelines one need to evaluate prior to getting involved in an FRC contract. Services rendered by the contract should be identified to know the range of responsibilities the group will provide. The advanced knowledge on how much premium for administration, marketing and profits the group will earn, and how the full responsibility to the patients are rendered should also be examined., Managing specialty as well as primary care can profit you handsomely - if you know what you're doing. Here's what's involved. If you want a shot at the profits that [...]

The federal government has contracted provider-sponsored organizations (PSOs) to provide Medicare beneficiaries additional options in selecting managed-care services other than what health maintenance organizations offer. The Health Care Financing Administration assumes that through licensing physician-owned health care providers, the rate of Medicare patients enrolled in health plans will increase. However, the success of PSO's lie in their acquisition of state license, substantial capital and ability to overcome potential legal, ethical and financial obstacles., As part of its strategy to push more Medicare beneficiaries into managed-care plans, the federal government wants to start contracting directly with provider-sponsored organizations such as group practices, PHOs, IPAs, [...]

There was a pronounced change in the health delivery system in the US since the late 1980s. The change was brought about by shifting the responsibility for the delivery of health care from independent entities such as physicians and hospitals to managed care providers. Increasingly, the delivery of health care is becoming a profit-making operation to the detriment of health services and dissatisfaction among patients and physicians. Events and policies that brought about changes in health care delivery are discussed.

One possible method to evaluate the quality of a health care system is to compare the actual care received to the care expected, as determined by Ambulatory Care Groups (ACGs) which are based on age, gender, and diagnosis. A total of 14,688 children in a Florida Healthy Kids Program utilized five health maintenance organizations for their care. ACGs software determined the expected care adjusted for case mix by weighting for diagnoses that would affect the average care required. Statistical differences were seen between sites but, generally, the children received adequate care., Background. In 1990, the Florida Legislature established the Florida Healthy Kids Corporation to implement the concept of school enrollment-based health insurance coverage for children. The county school districts are used as a grouping mechanism to negotiate health insurance policies. The Florida Healthy Kids Corporation negotiates contracts with health maintenance organizations (HMOs) to assume financial risk and to provide health care services at each program site. In 1994, there were five sites with four different participating HMOs. Assessing quality of care is particularly important when contracting with HMOs because of the perception that financial and utilization review arrangements may restrict the enrollees' access to needed health care. One essential component of health care quality is the extent to which health care services are used in a manner consistent with the expected pattern of use for the population of enrolled children. The purpose of this study is to compare children's health care use across five different Florida Healthy Kids Program sites. Specifically, we compare the enrollees' actual health care use across HMO settings and program sites to the expected health care use based on the enrollees' case-mix. Methods. Each HMO provided child-specific health care use data including Physician's Current Procedural Terminology codes and International Classification of Diseases, 9th Revision codes. We used the Ambulatory Care Groups (ACGs) software to compare the children's actual health care use to the expected health care use at each site adjusted for case-mix. Several steps were then taken to determine if the children were receiving the anticipated number of health care visits based on their diagnoses. First, we divided the average number of encounters at each site by the group average across all of the sites, without adjusting for the case-mix of the enrollees. We then divided the average number of visits at each site by the expected number of visits based on the case-mix adjustment. A value of 1.00 means that the actual use and the expected use are identical. Values below 1 indicate underuse and values over 1 indicate overuse of health care services. Statistical comparisons of the actual versus expected average health care use across the five sites were performed by deriving the appropriate [chi square] statistics. Results. A census of all children (N = 14 688) enrolled in the Florida Healthy Kids Program at each of the sites for 6 months or longer were included in the analysis. The average number of health care encounters across all sites for a 12-month time period was 2.98 [+ or -] 4.6 visits. After adjusting for the case-mix of the enrollees in each site using the ACG software, several of the five sites differed from one in a statistically significant way. However, these statistical assessments must be tempered with assessing the practical magnitude of the observed differences. Conclusions. The number of public and private efforts to insure children who are not eligible for Medicaid and whose parents cannot purchase private insurance has grown dramatically. These programs are vital for ensuring financial access to care for uninsured children. However, it is essential that such programs are not viewed as merely cost containment efforts. Assessing the degree to which children receive the health care services they need across multiple delivery settings is an essential yet challenging component of quality assurance. Generally, our analysis indicates that children in the Florida Healthy Kids Program are receiving the amount of health care expected based on their health care needs; which is one component of a high-quality health care program. Pediatrics 1997;100:947-953; pediatrics, managed care, case-mix adjustment, health care reform., ABBREVIATIONS: HMOs, health maintenance organizations; ACGs, Ambulatory Care Groups (software); ADGs, ambulatory diagnostic groups. Beginning in the 1980s, many states began developing health insurance programs for uninsured children that were [...]

Fee-for-service health maintenance organizations (HMOs) create problems for several primary-care physicians. Consultants claim that the plans these HMOs offer often pay more slowly as compared to those from preferred provider organizations and indemnity insurers. Physicians are suggested to be more cautious to the adherence of their staff to each plan's policy and to verify their patients' plan eligibilities to prevent problems whenever HMOs do not pay on time., This frustrating problem won't go away unless you attack it head on. Experts outline the best steps to take. Once upon a time, "collection" meant dunning patients for overdue bills. [...]

There is an uncertainty as to whether elderly patients can be entrusted to health maintenance organizations (HMOs) now that individuals covered by Medicare are being transferred to HMOs. To be sure, physicians should first determine which between the HMO or a specific provider group is in control of the health care. They should then appraise the organization that calls the shots to find out if the right service can indeed by guaranteed to vulnerable senior citizens., As HMOs step up efforts to enroll Medicare enrollees, this is becoming a pressing question. We set out to find the answer. Thirteen percent of the elderly and disabled Americans [...]