The metamorphosis of managed care: implications for health reform internationally.

The conventional wisdom is that managed care's brief life is over and we are now in a post-managed care era. In fact, managed care has a long history and continues to thrive. Writers also often assume that managed care is a fixed thing. They overlook that managed care has evolved and neglect to examine the role that it plays in the health system. Furthermore, private actors and the state have used managed care tools to promote diverse goals. These include the following: increasing access to medical care; restricting physician entrepreneurialism; challenging professional control over the medical economy; curbing medical spending; managing medical practice and markets; furthering the growth of medical markets and private insurance; promoting for-profit medical facilities and insurers; earning bounties for reducing medical expenditures: and reducing governmental responsibility for, and oversight of, medical care. Struggles over these competing goals spurred the metamorphosis of managed care. This article explores how managed care transformed physicians' conflicts of interests and responses to them. It also examines how managed care altered the opportunities for patients/medical consumers to use exit and voice to spur change.

Access intervention in an integrated, prepaid group practice: effects on primary care physician productivity.

OBJECTIVE: To estimate the joint effect of a multifaceted access intervention on primary care physician (PCP) productivity in a large, integrated prepaid group practice. DATA SOURCES: Administrative records of physician characteristics, compensation and full-time equivalent (FTE) data, linked to enrollee utilization and cost information. STUDY DESIGN: Dependent measures per quarter per FTE were office visits, work relative value units (WRVUs), WRVUs per visit, panel size, and total cost per member per quarter (PMPQ), for PCPs employed >0.25 FTE. General estimating equation regression models were included provider and enrollee characteristics. PRINCIPAL FINDINGS: Panel size and RVUs per visit rose, while visits per FTE and PMPQ cost declined significantly between baseline and full implementation. Panel size rose and visits per FTE declined from baseline through rollout and full implementation. RVUs per visit and RVUs per FTE first declined, and then increased, for a significant net increase of RVUs per visit and an insignificant rise in RVUs per FTE between baseline and full implementation. PMPQ cost rose between baseline and rollout and then declined, for a significant overall decline between baseline and full implementation. CONCLUSIONS: This organization-wide access intervention was associated with improvements in several dimensions in PCP productivity and gains in clinical efficiency.

Prepaid group using prevention focus to lure back employers.

Prepaid medical groups like Grand Valley Health Plan, Grand Rapids, MI, are facing declining membership as employers shift to lower-priced PPOs. But some employers are starting to look more closely again at the value of managed care networks.

Implementing evidence-based practices to improve quality. One medical group's experience.

HealthPartners Medical Group and Clinics uses evidence-based guidelines for diabetes and other chronic diseases. This article reviews how HealthPartners has redesigned its care processes and implements the diabetes guidelines. It also summarizes the lessons the organization has learned about how to choose guidelines and how to get the most from them.

Physicians and prepaid group practices.

Prepaid group practices (PGPs) are complex organizations that directly combine prepayment for health care with a comprehensive health care delivery system. PGPs' ability to manage their physician staffing efficiently must be placed in context with the cost and quality of their care. It seems unlikely that PGPs or their use of staff will proliferate. With increased integration of care through disease management programs and use of clinical information technology, it should be possible for the United States as a whole to come closer to achieving the care delivery goals that PGPs have set in the past.

Benefits and pitfalls in applying the experience of prepaid group practices to the U.S. physician supply.

The paper by Jonathan Weiner includes important improvements in the methodology used to compare the physician workforce in prepaid group practices (PGPs) with the U.S. physician workforce. It also provides valuable insights for policymakers and researchers. Despite the improvements, concerns remain regarding the comparability of the populations served and physician activities in PGPs and the country as a whole. While PGPs appear to offer valuable lessons on how to use physicians effectively and efficiently, it is inappropriate to use the PGP physician rates to determine the number of physicians needed in the United States.

The changing shape of the physician workforce in prepaid group practice.

Multiple factors have combined to change the size and specialty composition of the physician workforce in the nation's largest prepaid group practices over the past two decades. An examination of these changes can shed some light on the past and potential future impact that changes in medical technology are likely to have on the physician workforce of these organizations and the greater physician community.

Prepaid group practice staffing and U.S. physician supply: lessons for workforce policy.

This paper describes staffing at eight large prepaid group practices (PGPs) serving more than eight million enrollees at Kaiser Permanente and two other health maintenance organizations (HMOs). Even after characteristics of the patient populations and outside referrals are accounted for, these PGPs have a physician-to-population ratio that is 22-37 percent below the national rate. Two decades of historical data at Kaiser Permanente indicate that its rate of specialist growth was far higher than that of primary care. The study suggests that efficient systems of care can readily meet the demands of patient populations with workforce staffing ratios below current U.S. levels.

Prepaid group practices offer lessons in staffing ratios.

Capitated physician organizations and prepaid group practices share many similarities in staffing, care processes and infrastructure. Use these benchmarks to help conduct physician workforce planning.

Capitated groups track claims, reduce costs using MD Hawkeye.

The "MD Hawkeye" software program from Doctor-Driven Systems helps capitated groups manage costs, reduce utilization, and improve quality measurements. See how one capitated group saved more than $100,000 on one project.