Does Medicaid managed care market penetration impact provider participation, costs, utilization, and access?

Key findings. (1) An increase in commercial plan penetration increased the liklihood [sic] that a physician would accept new Medicaid patients, but this did not significantly impact enrollee costs. (2) An increase in Medicaid-dominant HMO market penetration increased the probability that individuals reported using the ED as their primary source of care.

The group employed model as a foundation for health care delivery reform.

With a focus on delivering low-cost, high-quality care, several organizations using the group employed model (GEM)-with physician groups whose primary and specialty care physicians are salaried or under contract-have been recognized for creating a culture of patient-centeredness and accountability, even in a toxic fee-for-service environment. The elements that leaders of such organizations identify as key to their success are physician leadership that promotes trust in the organization, integration that promotes teamwork and coordination, governance and strategy that drive results, transparency and health information technology that drive continual quality improvement, and a culture of accountability that focuses providers on patient needs and responsibility for effective care and efficient use of resources. These organizations provide important lessons for health care delivery system reform.

What are the costs to physicians of administrative complexity in their interactions with payers?

(1) Primary care physicians spent significantly more time on administrative tasks than did medical specialists or surgical specialists. (2) All staff in physician practices with one or two physicians spent more time on administrative tasks than did physicians and staff in practices with more than 10 physicians. (3) More than 75 percent of physicians and administrators reported that the administrative burden of interacting with a health plan increased significantly or increased slightly in the past two years.

Getting tools used: lessons learned from successful decision support tools unrelated to health care.

(1) The success of decision support tools outside of health care derives from focusing on decisions important to consumers, tailoring content to consumers' concerns and needs, and sponsorship by an independent, trusted organization with a business model that supports sustained marketing and refinement. (2) Current approaches to decision support tools within health care will benefit from basing future efforts on a clearer understanding of the interests and capacities of target audiences, as well as providing information that aligns with both the timing and range of decisions health care consumers face. In addition, there must be a thoughtful approach to building consumer trust accompanied by a long-term funding commitment or revenue model that will enable decision support tools to become a familiar, expected aspect of health care

How valid are the assumptions underlying consumer-driven health plans?

(1) While consumer-driven health plans (CDHPs) do encourage information seeking behavior, these plans attract individuals who are already activated consumers. (2) The financial incentives inherent in CDHPs cause consumers to decrease utilization of both high and low priority services.(3) Individuals enrolled in high-deductible CDHPs are most likely to discontinue lipid lowering and antihypertensive drugs after enrolling in a CDHP.

Informing the debate: are single specialty hospitals more cost efficient than full-service hospitals?

(1) Overall, single specialty hospitals (SSHs) are not more cost efficient than competing, full-service, acute care hospitals. (2) There was not a significant difference between cardiac SSH and full-service hospital cost inefficiency. (3) There was a significant difference between orthopedic/surgical SSH and full-service hospital cost inefficiency.

Medicare Advantage and the impact of Medicare HMOs on inpatient utilization.

(1) Health maintenance organizations (HMOs) decrease inpatient utilization for Medicare enrollees. (2) California group and staff HMO enrollees used 18 percent fewer inpatient days than had they continued in Medicare fee-for-service (FFS) plans, with an 11 percent reduction for independent practice association (IPA) HMO enrollees.