A randomized controlled open trial of population-based disease and case management in a Medicare Plus Choice health maintenance organization.

Introduction: The object of this study was to examine the effect of population-based disease management and case management on resource use, self-reported health status, and member satisfaction with and retention in a Medicare Plus Choice health maintenance organization (HMO).

Methods: Study design consisted of a prospective, randomized controlled open trial of 18 months' duration. Participants were 8504 Medicare beneficiaries aged 65 and older who had been continuously enrolled for at least 12 months in a network model Medicare Plus Choice HMO serving a contiguous nine-county metropolitan area.

What care should be covered?

The answer to the question of what health care services should be covered by a managed care plan is straightforward; the plan should cover whatever the consumer is willing to pay for. From the plan's perspective, the consumer is the payer, that is, the employer who negotiates the plan; not the individual patient whose personal preferences and interests may be quite different. Since managed care organizations contract with payers to arrange for health care services within a defined set of benefits, there is a broader question as well: Within the benefits chosen by the payer, what actually is covered? Criteria for determining "medical necessity," which managed care plans frequently use as the basis for coverage, are discussed.

Cost of acid peptic disorders in a managed-care organization.

The purpose of this study was to determine the cost of managing ambulatory patients with symptoms of acid peptic disorders in a managed-care organization under actual clinical conditions. Study data were collected in a large independent practice association model health maintenance organization in Gainesville, Florida, from prescription records maintained in a computerized database and from patient medical records. Patients had to be started on a histamine2-receptor antagonist (H2RA) or the proton pump inhibitor omeprazole between 1992 and 1994.