[Show abstract][Hide abstract] ABSTRACT: Managed care has the potential to transform fundamentally the structure and functioning of the entire health care system, including the care provided to patients who are not enrolled in managed care plans.
To determine whether increasing health maintenance organization (HMO) market share is associated with decreased expenditures for the care of patients covered by Medicare's traditional fee-for-service plan, a group cared for well outside the boundaries of managed care.
Data from the Health Care Financing Administration were used to compare expenditures for the care of Medicare fee-for-service beneficiaries for 802 market areas, representing the entire United States, for 1990 to 1994. These data were matched with data on system-wide (Medicare and non-Medicare) HMO market share in these areas.
All fee-for-service Medicare beneficiaries (1990-1994) except for those with end-stage renal disease.
Average fee-for-service expenditure per fee-for-service Medicare beneficiary by market area.
In a regression model, increases in system-wide HMO market share were associated with declines in both Part A and Part B fee-for-service expenditures per Medicare beneficiary (P<.001). Increases from 10% market share to 20% market share were associated with 2.0% decreases in Part A fee-for-service expenditures and 1.5% decreases in Part B fee-for-service expenditures.
Managed care can have widespread effects on the health care system. Health care for individuals who are not covered by managed care organizations can be influenced by the presence of managed care. Lower expenditures in areas with high HMO market shares may indicate that traditional Medicare beneficiaries in areas with high market shares received fewer or less intensive services than traditional Medicare beneficiaries in other areas.
JAMA The Journal of the American Medical Association 02/1999; 281(5):432-7. DOI:10.1001/jama.281.5.432 · 35.29 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: In 2009, Blue Cross Blue Shield of Massachusetts (BCBS) implemented a global payment system called the Alternative Quality Contract (AQC). Provider groups in the AQC system assume accountability for spending, similar to accountable care organizations that bear financial risk. Moreover, groups are eligible to receive bonuses for quality.
Seven provider organizations began 5-year contracts as part of the AQC system in 2009. We analyzed 2006-2009 claims for 380,142 enrollees whose primary care physicians (PCPs) were in the AQC system (intervention group) and for 1,351,446 enrollees whose PCPs were not in the system (control group). We used a propensity-weighted difference-in-differences approach, adjusting for age, sex, health status, and secular trends to isolate the treatment effect of the AQC in comparisons of spending and quality between the intervention group and the control group.
Average spending increased for enrollees in both the intervention and control groups in 2009, but the increase was smaller for enrollees in the intervention group--$15.51 (1.9%) less per quarter (P=0.007). Savings derived largely from shifts in outpatient care toward facilities with lower fees; from lower expenditures for procedures, imaging, and testing; and from a reduction in spending for enrollees with the highest expected spending. The AQC system was associated with an improvement in performance on measures of the quality of the management of chronic conditions in adults (P<0.001) and of pediatric care (P=0.001), but not of adult preventive care. All AQC groups met 2009 budget targets and earned surpluses. Total BCBS payments to AQC groups, including bonuses for quality, are likely to have exceeded the estimated savings in year 1.
The AQC system was associated with a modest slowing of spending growth and improved quality of care in 2009. Savings were achieved through changes in referral patterns rather than through changes in utilization. The long-term effect of the AQC system on spending growth depends on future budget targets and providers' ability to further improve efficiencies in practice. (Funded by the Commonwealth Fund and others.).
New England Journal of Medicine 07/2011; 365(10):909-18. DOI:10.1056/NEJMsa1101416 · 55.87 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Seven provider organizations in Massachusetts entered the Blue Cross Blue Shield Alternative Quality Contract in 2009, followed by four more organizations in 2010. This contract, based on a global budget and pay-for-performance for achieving certain quality benchmarks, places providers at risk for excessive spending and rewards them for quality, similar to the new Pioneer Accountable Care Organizations in Medicare. We analyzed changes in spending and quality associated with the Alternative Quality Contract and found that the rate of increase in spending slowed compared to control groups, more so in the second year than in the first. Overall, participation in the contract over two years led to savings of 2.8 percent (1.9 percent in year 1 and 3.3 percent in year 2) compared to spending in nonparticipating groups. Savings were accounted for by lower prices achieved through shifting procedures, imaging, and tests to facilities with lower fees, as well as reduced utilization among some groups. Quality of care also improved compared to control organizations, with chronic care management, adult preventive care, and pediatric care within the contracting groups improving more in year 2 than in year 1. These results suggest that global budgets with pay-for-performance can begin to slow underlying growth in medical spending while improving quality of care.
Health Affairs 07/2012; 31(8):1885-94. DOI:10.1377/hlthaff.2012.0327 · 4.97 Impact Factor
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