La separación de los servicios de prevención ajenos de las mutuas: otro mundo es posible / The separation of external prevention services from the insurance companies: another world is possible

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The effects of HMO ownership on hospital costs and revenues: is there a difference between for-profit and nonprofit plans?

We conducted multivariate analyses to examine whether high health maintenance organization (HMO) penetration and large share of for-profit health plans in a market reduced hospital cost and revenue growth rates between 1989 and 1998. We found that hospitals in high HMO areas experienced revenue and cost growth rates that were 21 and 18 percentage points, respectively, below hospitals in low HMO areas. We also found that, conditional on overall HMO penetration level, hospitals in areas with high for-profit HMO penetration experienced revenue and cost growth rates that were 10 percentage points below hospitals in areas with low for-profit penetration areas; the difference was especially evident within high HMO penetration areas.

Measuring community benefits provided by nonprofit and for-profit HMOs.

Despite the dramatic shift from nonprofit to for-profit ownership in the managed care industry, little is known about the implications for health plans' relations with the communities in which they operate. This paper provides the first comprehensive comparison of the community benefit activities of nonprofit and for-profit health maintenance organizations (HMOs). We develop a conceptual framework for identifying these activities and provide evidence from a nationally representative survey of plans fielded in 1999. We find that nonprofit plans exceed their for-profit counterparts on some, but not all, aspects of community benefit activity. The most consistent ownership-related differences involve redistributive programs (subsidized services and general philanthropy), commitments to medical research, and services that benefit the entire local population, beyond the plan's enrollees. Other forms of community benefits show mixed or modest differences between nonprofit and for-profit plans. Unexpectedly, for-profit plans actually appear more active in helping consumers deal with information asymmetries. The paper concludes with a discussion of implications for policy and future research.

Ethical climate in managed care organizations.

Managed care organizations employ nurses as medical utilization reviewers; however, little is known about the ethical climate of these organizations. This study describes different ethical climates in which utilization review nurses work and the implications of these differences for nurse administrators. The nurse participants, although demographically similar across three managed care organizations, perceived distinct ethical climates across the organizations. Nurses were employed to make complex decisions regarding medical care utilization; however, none of the organizations had an ethics committee to help nurse reviewers in this decision-making process. The need for such committees, as well as clarification of a consistent and deliberate ethical climate by nurse administrators, is discussed.

Effects of CAHPS health plan performance information on plan choices by New Jersey Medicaid beneficiaries.

OBJECTIVE: To assess the effects of CAHPS health plan performance information on plan choices and decision processes by New Jersey Medicaid beneficiaries. DATA SOURCES/STUDY SETTING: The study sample was a statewide sample of all new Medicaid cases that chose Medicaid health plans during April 1998. The study used state data on health maintenance organization (HMO) enrollments and survey data for a subset of these cases. STUDY DESIGN: An experimental design was used, with new Medicaid cases randomly assigned to experimental or control groups. The experimental group received a CAHPS report along with the standard enrollment materials, and the control group did not. DATA COLLECTION: The HMO enrollment data were obtained from the state in June 1998, and evaluation survey data were collected from July to October 1998. PRINCIPAL FINDINGS: No effects of CAHPS information on HMO choices were found for the total sample. Further examination revealed that only about half the Medicaid cases said they received and read the plan report and there was an HMO with dominant Medicaid market share but low CAHPS performance scores. The subset of cases who read the report and did not choose this dominant HMO chose HMOs with higher CAHPS scores, on average, than did those in an equivalent control group. CONCLUSIONS: Health plan performance information can influence plan choices by Medicaid beneficiaries, but will do so only if they actually read it. These findings suggest a need for enhancing dissemination of the information as well as further education to encourage informed choices.

Relationship between low quality-of-care scores and HMOs' subsequent public disclosure of quality-of-care scores.

CONTEXT: Public disclosure of quality data on health maintenance organizations (HMOs) might improve public accountability, inform consumer decision making, and promote quality improvement. But, because disclosure is voluntary, some HMOs could subvert these objectives by refusing to release unfavorable data. OBJECTIVE: To determine the association between HMO quality of care and withdrawal from public disclosure of quality-of-care data the subsequent year. DESIGN AND SETTING: Retrospective cohort study of administrative and quality-of-care data on HMOs from the National Committee for Quality Assurance (NCQA) annual Quality Compass databases for 1997, 1998, and 1999, including Health Plan Employer Data and Information Set (HEDIS) quality scores. MAIN OUTCOME MEASURE: One-year rates of HMO withdrawal from public disclosure of HEDIS scores for plans in the highest and lowest tertiles of HEDIS scores, adjusted for method of data collection and plan model type. RESULTS: Of the 329 HMOs that publicly disclosed HEDIS scores in 1997, 161 plans (49%) withdrew from public disclosure in 1998. Of the 292 HMOs that disclosed their scores in 1998 (including 130 newly participating plans), 67 plans (23%) withdrew from public disclosure in 1999. Plans whose scores ranked in the lowest-quality tertile were much more likely than plans ranking in the highest-quality tertile to withdraw from public disclosure in 1998 (odds ratio [OR], 3.6; 95% confidence interval [CI], 2.1-7.0) and 1999 (OR, 5.7; 95% CI, 2.7-17.7). CONCLUSION: Compared with HMOs receiving higher quality-of-care scores, lower-scoring plans are more likely to stop disclosing their quality data. Voluntary reporting of quality data by HMOs is ineffective; selective nondisclosure undermines both informed consumer decision making and public accountability.

Effect of CAHPS performance information on health plan choices by Iowa Medicaid beneficiaries.

This evaluation tested if Consumer Assessment of Health Plans Study (CAHPS) information on plan performance affected health plan choices by new beneficiaries in Iowa Medicaid. New cases entering Medicaid in selected counties during February through May 2000 were assigned randomly to experimental or control groups. The control group received standard Medicaid enrollment materials, and the experimental group received these materials plus a CAHPS report. We found that CAHPS information did not affect health plan choices by Iowa Medicaid beneficiaries, similar to previously reported findings for New Jersey Medicaid. However, it did affect plan choice in an earlier laboratory experiment. The value of this information may be limited to a subset of receptive consumers who actively study information received, even then only when (1) ratings of available plans differ greatly, (2) ratings differ from prior beliefs about plan quality, and (3) reports are easy to understand.

Consumer beliefs and health plan performance: it's not whether you are in an HMO but whether you think you are.

Surveys that rate how persons enrolled in HMOs and other types of health coverage feel about their health care are used to bolster claims that HMOs provide inferior quality care, providing justification for patient protection legislation. This research illustrates that the conventional wisdom regarding inferior care in HMOs may color how people assess their health care in surveys, resulting in survey findings biased toward showing HMOs provide inferior care and reinforcing existing stereotypes. Using merged data from the Community Tracking Study Household and Insurance Followback surveys, we identify privately insured persons who correctly and incorrectly know what kind of health plan they are covered by. Nearly a quarter misidentified their type of health coverage. Differences between responses by HMO and non-HMO enrollees to questions covering satisfaction with health care and physician choice, the quality of the last physician's visit, and patient trust in their physician shrink or disappear when we control for beliefs about what type of plan they are covered by. Results suggest that researchers and policy makers should be cautious about using consumer surveys to assess the relative quality of care provided under different types of health insurance.

Development of a scale to measure patients' trust in health insurers.

OBJECTIVE: To develop a scale to measure patients' trust in health insurers, including public and private insurers and both indemnity and managed care. A scale was developed based on our conceptual model of insurer trust. The scale was analyzed for its factor structure, internal consistency, construct validity, and other psychometric properties. DATA SOURCES/STUDY SETTING: The scale was developed and validated on a random national sample (n = 410) of subjects with any type of insurance and further validated and used in a regional random sample of members of an HMO in North Carolina (n = 1152). STUDY DESIGN: Factor analysis was used to uncover the underlying dimensions of the scale. Internal consistency was assessed by Cronbach's alpha. Construct validity was established by Pearson or Spearman correlations and t tests. DATA COLLECTION: Data were collected via telephone interviews. PRINCIPAL FINDINGS: The 11-item scale has good internal consistency (alpha = 0.92/ 0.89) and response variability (range = 11-55, M = 36.5/37.0, SD = 7.8/7.0). Insurer trust is a unidimensional construct and is related to trust in physicians, satisfaction with care and with insurer, having enough choice in selecting health insurer, no prior disputes with health insurer, type of insurer, and desire to remain with insurer. CONCLUSIONS: Trust in health insurers can be validly and reliably measured. Additional studies are required to learn more about what factors affect insurer trust and whether differences and changes in insurer trust affect actual behaviors and other outcomes of interest.

The impact of health plan report cards on managed care enrollment.

How does the release of health plan performance ratings influence employee health plan choice? A natural experiment at General Motors (GM) Corporation provides valuable evidence on this question. During the 1997 open enrollment period, GM disseminated a health plan report card for the first time. By comparing 1996 and 1997 enrollment patterns, our analysis estimates the impact of the report card information while accounting for fixed, unobserved plan traits. Results indicate that employees are less likely to enroll in plans requiring relatively high out-of-pocket contributions. Results with respect to report card ratings suggest that individuals avoid health plans with many below average ratings.

Organizational context and taxonomy of health care databases.

An understanding of the organizational context and taxonomy of health care databases is essential to appropriately use these data sources for research purposes. Characteristics of the organizational structure of the specific health care setting, including the model type, financial arrangement, and provider access, have implications for accessing and using this data effectively. Additionally, the benefit coverage environment may affect the utility of health care databases to address specific research questions. Coverage considerations that affect pharmacoepidemiologic research include eligibility, the nature of the pharmacy benefit, and regulatory aspects of the treatment under consideration.