Today's managed care market: examining the effectiveness of the "gatekeeper" mechanism

Article Abstract:

Point-of-service (POS) systems of care, where there is a stronger incentive for members to use network physicians, may be as effective or even more effective for managing moderately resource-intensive conditions than preferred provider organization (PPO) plans. This was gleaned from the results of a natural experiment in one region where the effect of the 'gatekeeper' mechanism could be examined. A patterns-of-treatment study involving a large employer whose members were enrolled in a PPO plan and a POS plan revealed that the overall charge per patient treatment episode was 29% lower in the POS system of care.

HEALTH SERVICES, Direct Health and Medical Insurance Carriers, Hospital and medical service plans, Medical Care Insurance, Preferred Provider Health Plans, Analysis, Health insurance, Preferred provider organizations (Medical care)

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Evaluating health plan efficiency

Article Abstract:

First-generation claims data systems of the 1970s focused mostly on analyzing charge and utilization excesses for hospitalized patients. When costs of ambulatory services increased, employers saw the need to monitor both hospital and ambulatory experience to find out thefactors causing benefit cost increases. However, second-generation data analysis systems focusing on ambulatory utilization and charges also have theirshortcomings. Third-generation claims systems, which use 'per episode of care' as unit of analysis instead of 'per 1,000 individuals,' give more accurate assessments.

Management, Medical care, Medical care, Cost of, Health care costs, Medical care utilization, Health services administration

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Developing capitation rates for disease management programs

Article Abstract:

The pharmaceutical industry is using a new approach to market prescription drug products. Drug companies are introducing capitated disease management programs, particularly those designed to treat arthritis, asthma, diabetes, cancer and other chronic diseases. In developing these programs, pharmaceutical firms usually formulate and implement disease management guidelines, capitate all treatment services on a yearly basis, include their products in the program's formulary, and adopt a continuous quality improvement strategy.

Pharmaceutical Preparation Manufacturing, Pharmaceutical preparations, Pharmaceutical industry, Drugs, Marketing, Capitated payment systems (Medical care)

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