Acute suprachoroidal hemorrhage during phacoemulsification.

We present a case of acute suprachoroidal hemorrhage that developed during routine phacoemulsification in an 85-year-old patient after uneventful administration of periocular anesthesia. Pre-existing risk factors included advanced age, glaucoma, myopia, and hypertension. The scleral tunnel prevented major expulsion of intraocular contents; however, raised intraocular pressure prevented intraocular lens implantation. The rarity of this condition raises questions regarding the further management and precautions related to it.

Should Medicare HMO benefits be standardized?

Legislation enacted in 1990 standardized Medigap benefits but not the benefits of health maintenance organizations (HMOs) that serve Medicare beneficiaries. An examination of marketing materials in two large counties reveals the potential for enormous confusion among beneficiaries because of differences in wording to describe the same benefit, health plans' failure to list Medicare-covered services, and the differences in the benefits themselves. To date, the Health Care Financing Administration (HCFA) has not been able to overcome this confusion through the comparative material distributed on its Web site; indeed, significant errors were found, reflecting to some extent the underlying difficulties in characterizing benefits. Ways of ameliorating the situation are discussed.

Identification and assessment of high-risk seniors. HMO Workgroup on Care Management.

CONTEXT: Many older adults with chronic illnesses and multidimensional needs are at high risk of adverse health outcomes, poor quality of life, and heavy use of health-related services. Modern proactive care of older populations includes identification of such high-risk individuals, assessment of their health-related needs, and interventions designed both to meet those needs and to prevent undesirable outcomes. OBJECTIVE: This paper outlines an approach to the tasks of identifying and assessing high-risk seniors. Intervention identification of high-risk seniors (also called case finding) is accomplished through a combination of periodic screening, recognition of high-risk seniors by clinicians, and analysis of administrative databases. Once identified, potentially high-risk individuals undergo on initial assessment in eight domains: cognition, medical conditions, medications, access to care, functional status, social situation, nutrition, and emotional status. The initial assessment is accomplished in a 30- to 45-minute interview conducted by a skilled professional--usually one with a background in nursing. The data are used to link some high-risk persons with appropriate services and to identify others who require more detailed assessments. Detailed assessment is often performed by interdisciplinary teams of various compositions and methods of operation, depending on local circumstances. CONCLUSION: The rapid growth in Medicare managed care is presenting many opportunities for developing more effective strategies for the proactive care for older populations. Identification and assessment of high-risk individuals are important initial steps in this process, paving the way for testing of interventions designed to reduce adverse health consequences and to improve the quality of life.

Applying managed care techniques in traditional Medicare.

Medicare has lagged behind the private sector in its reliance on managed care, which, properly done, has the potential to restrain budget growth and enhance quality. This paper addresses how the Medicare fee-for-service program--traditional Medicare--might apply managed care techniques. It first discusses the institutional constraints Medicare faces in implementing managed care techniques and then presents options for applying these techniques. I propose elements of an overall strategy to incorporate managed care in the fee-for-service program.

The impact of policy standardization on the Medigap market.

This study examines the impact of policy standardization on the market for Medicare supplemental, or "Medigap," policies. Prior to 1992, insurance carriers could sell any benefits they chose, so long as minimum benefit requirements were met. In July 1992, federal legislation was implemented that required all new Medigap policies to conform exactly to one of 10 standardized sets of benefits. Using pre- and post-standardized policy information from six states, this study analyzes the impact of this legislation. Overall, standardization has affected the market positively, and as a result, consumers are better able to make informed choices about the benefits they are purchasing.

Efforts to improve primary care delivery to nursing home residents.

OBJECTIVE: To describe a primary care practice model used by health maintenance organizations (HMOs) that serve medicare beneficiaries to improve the provision of primary care to nursing home residents. PARTICIPANTS: Medicare beneficiaries who reside in nursing homes and who are enrolled in HMOs. CONCLUSION: Several HMOs are using physician-nurse practitioner teams to provide primary care to nursing home residents. The potential to improve the delivery of these services in nursing homes, particularly to long-stay residents, is apparent. However, obstacles arise in developing this practice model in HMOs, including difficulty recruiting both nurse practitioners and physicians and the lack of HMO-based research on the effects of such a model.

Medigap reform legislation of 1990: have the objectives been met?

The 1990 medigap reform legislation had multiple objectives: To simplify the insurance market in order to facilitate policy comparison, provide consumer choice, provide market stability, promote competition, and avoid adverse selection. Based on case study interviews with a cross-section of individuals and organizations, we report that most of these objectives have been achieved. Consumers of medigap plans are able to make more informed choices, largely because they can adequately compare policies based on standard benefits. Marketing abuses have apparently declined, as evidenced by a decrease in the number of consumer complaints. Finally, no major detrimental impact on the insurance industry was detected. Beneficiaries still face some confusion in this market, however, such as understanding the rating methodologies used to set premiums and how this may affect their choices. Confusion could increase with the growth of managed care options.

Managed care and chronic illness: an overview.

The growth in managed care raises a number of issues with respect to people with chronic illness. One issue is whether HMOs enroll their fair share of people with chronic illness. Another issue is how to address the fears among people with chronic illness or disabilities who are faced with requirements to join managed care plans.

Medigap regulation: lessons for health care reform.

Congress enacted legislation in 1990 that dramatically changed the rules for selling supplemental health insurance, or "Medigap" policies, to the elderly. Most notably, policy coverage was standardized. Insurance carriers are allowed to sell only the ten specified packages of benefits, which reduces consumer choice but facilitates comparison shopping. This legislation is important in its own right and also offers lessons for U.S. health care reform. To examine the changes brought about by this legislation and analyze their implications for health care reform, we conducted site visits to nine states and interviewed insurer representatives, executive branch officials, congressional staff, and various interest groups for two years.

Do HMOs care for the chronically ill?

This DataWatch refutes the notion that chronic illness is more prevalent among persons covered by indemnity insurance than by health maintenance organizations (HMOs). This is true even when health status and sociodemographic factors are accounted for in the analysis. The study analyzes the prevalence of chronic illness among privately insured nonelderly persons in HMOs and indemnity plans, using data from the 1992 National Health Interview Survey. More data are needed to examine this issue for Medicare and Medicaid populations.

Can regulation improve long-term care insurance? Lessons from the Medigap experience.

This article uses recent experiences from the Medigap market to draw conclusions about the advisability of alternative methods of regulating the market for long-term care insurance. The analysis is based in part on interviews of state insurance regulators, insurance companies, and interest-group representatives. The authors conclude that some regulation of the market is appropriate, but that the structure and extent of regulation found in the Medigap market would likely be inappropriate for the long-term care insurance market at this time.

Aggressive management of an epidemic of chronic pseudophakic endophthalmitis: results and literature survey.

Six cases of chronic endophthalmitis following extracapsular cataract extraction and lens implantation are reviewed. All were referred for tertiary management by one surgeon over a period of just over 2 years. In two of the cases coagulase negative staphylococci were isolated and in three Propionibacterium spp were retrieved. In the remaining case a mixed growth of coagulase negative staphylococci and Propionibacterium acnes was cultured. The surgical management, microbiological results, and eventual visual outcome are discussed. To our knowledge, this is the first documented outbreak of chronic pseudophakic endophthalmitis with commensal organisms from a single centre.

Influence of alpha thalassaemia on the retinopathy of homozygous sickle cell disease.

Homozygous alpha+ thalassaemia (alpha-/alpha-) ameliorates some of the clinical manifestations of homozygous sickle cell (SS) disease but its effect on retinal complications remains unknown. This has been assessed by visual examination and fluorescein angiography in 39 subjects with SS disease and homozygous alpha+ thalassaemia and in 39 age/sex matched controls with SS disease but with a normal alpha globin genotype (alpha alpha/alpha alpha). The results indicate that homozygous alpha+ thalassaemia reduces the extent of peripheral retinal vessel closure but has no apparent effect on the frequency of proliferative sickle retinopathy.

Laser photocoagulation for proliferative retinopathy in sickle haemoglobin C disease.

The effect of sectoral, scatter laser photocoagulation on proliferative sickle retinopathy (PSR) was investigated by reviewing fluorescein angiograms of 88 sickle cell-haemoglobin C patients enrolled in a controlled, randomised trial. Follow-up was for a median period of 2.9 years. Complete infarction of all PSR in an eye occurred in 7 of 74 treated eyes and 2 of 60 control eyes. Treatment resulted in significantly greater regression (decrease in number or size of PSR lesions) in eyes of patients aged < 25 years at enrollment but not in eyes of patients > or = 25 years at enrollment. Infarction of individual PSR lesions was significantly more common in treated eyes. Treated PSR was significantly more likely to infarct if small (< 15 degrees circumferential involvement) and if flat rather than elevated. New PSR was significantly less likely to develop in treated eyes.