1. Managed Care: Your Population N226 Winter 2003 Professor: Joanne Spetz 5 February 2003

2. Purpose of this lecture Think more carefully about managed care’s effects on different patient populations How do we define a patient population? What do we expect for different populations? What implications does this have for case management?

3. How to group patients? By type of illness Physical health  Healthy population  Certain illness classes Chronic illness Acute illness Mental health  Chronic  Acute

4. How to group patients? (cont.) By setting of care Inpatient Doctors’ office Public health clinic Mental health setting  Inpatient  Outpatient

5. How to group patients? (cont.) By age of population Children Adults Elderly By socioeconomic category Income Language Employment Education

6. How to group patients? (cont.) By insurance coverage Has insurance or not Type of insurance  Private  Medicare  Medicaid Managed care or not  Type of managed care  Particular managed care plan

7. What are the needs of your population? Physical needs Ongoing care Immediate care Mental needs Mental illness  Acute vs. chronic Validation and caring

8. What are the needs of your population? (continued) Access needs Money Transportation Time Education needs The patient’s illness/health The patient’s insurance coverage Options for care  Types of care  Specific locations/venues for care

9. What are the needs of your population? (continued) Some nuances Elderly  Durable power of attorney  DNR orders and such Children  Parents’ involvement in the care  Children’s understanding of illness, treatment

10. How should managed care affect quality? In general By illness Chronically ill Mental health By setting of care Inpatient Outpatient Public health clinic

11. How should managed care affect quality? (continued) By age of population By socioeconomic category Poor versus nonpoor Language Education of patient

12. How should managed care affect quality? (continued) By insurance coverage Uninsured Medicare Medicaid HMO/gatekeeping PPO

13. What effect has managed care had? In general Miller & Luft (1997) reviewed 15 studies on quality of care and found equal number of better/worse results Dudley et al. (1998) find no clear mortality effect in lit review Ware et al. (1996) finds no difference for overall population

14. What effect has managed care had? (continued) By illness – Healthy patients & acute care Dudley et al. (1998) find studies show better preventive services in HMOs Hellinger (1998) reports similar outcomes for cancer/stroke Medicare patients

15. What effect has managed care had? (continued) By illness - Chronically ill Luft & Miller (1997) – Medicare enrollees with chronic conditions get lower quality Dudley et al. (1998) find better home health use in FFS Hellinger (1998) reports less improvement for Medicare with chronic joint pain

16. What effect has managed care had? (continued) By illness - Mental health Miller & Luft (1997) report higher quality for elders with chronic mental illness Ware et al. (1996) report no difference in general, but declines for poor patients Cuffel et al. (2002) finds no negative effect of capitation for Medicaid mental illness Meredith et al. (2001) finds more primary care provider continuity of care Libby et al. (2002) find children in capitated program receive less inpatient care, more residential treatment center care

17. What effect has managed care had? (continued) By setting of care – Outpatient Hemenway et al. (1990) demonstrated that financial incentives can induce a physician group to change practice pattern

18. What effect has managed care had? (continued) By age of population Hellinger (1998) reports Medicare patients (elderly) doing worse Ware et al. (1996) find more decline in physical health for elderly in HMOs Valdez et al. (1989) find more medical contacts and preventive services in HMOs, but no health outcomes difference

19. What effect has managed care had? (continued) By socioeconomic category Hellinger (1998) reports poorer outcomes for low income Ware et al. (1996) finds poor do worse in mental health in HMOs, but not in physical health

20. What effect has managed care had? (continued) By insurance coverage Medicare Medicaid