Measuring Quality in Modern Managed Care

Healthcare costs for the elderly are rising rapidly in the United States. One way for a hospital to control these rising costs is to implement a geriatric care management system. The goal of a system is to change the way the hospital treats medically complex Medicare patients and, thus, reduce unnecessary hospital costs. Such a system requires a process for identifying elderly patients in need of geriatric care management services, treating them efficiently, and assessing the system itself. An effective process usually results in significant cost savings for the hospital as well as improved patient care and satisfaction.

While people aged 65 and older make up 12 percent of the U.S. population, they account or 6 percent overall healthcare expenditures.(a) By the year 2000, the elderly population will be responsible for 58 percent of all hospital days and almost half of all healthcare expenditures.(b) Furthermore, fragmentation of services and funding sources makes it difficult for the elderly and their families to obtain appropriate care.

Thus, care management becomes extremely important in order to effectively address the increasing healthcare needs and costs of elderly Americans.

A geriatric care management system designed to restructure the delivery of care for Medicare patients is one way hospitals can control costs. Such a system is based on the concept that a relatively small proportion of Medicare patients must be targeted for focused care management in order for hospitals to increase the quality of care, avoid financial losses, and prevent poor clinical outcomes. The patients targeted are those who, without focused management, would account for the majority of hospital problems involving excessive resource use and long lengths of stay. Because these patients can be prospectively identified, focused care management techniques can be employed to ensure appropriate and efficient hospital care, thereby reducing lengths of stay and costs. The geriatric care management system thus provides hospitals with ways to reduce a patient’s length of stay and to use hospital resources more effectively.

The system focuses on three functions: identification of patients needing care management, geriatric care management intervention, and program performance evaluation. The performance evaluation provides information a hospital can use to improve the use of its resources and reduce patients’ lengths of stay.

IDENTIFICATION

The task of identifying Medicare patients who require geriatric care management starts with an analysis of hospital data related to discharge geriatric patients. This process involves analyzing hospital data to identify DRGs and admitting diagnoses as well as characteristics of patients and physicians associated with inappropriate lengths of stay; excessive resource use (such as laboratory, pharmacy, imaging services, procedures, and x-rays); or high costs. This analysis includes comparing hospital data with normative data such as national Medicare statistics and statistics from the managed care industry.

Using information obtained through the analysis of hospital data, a process can be designed to prospectively identify Medicare patients in need of geriatric care management. Patients targeted for care management will include those whose treatment is likely to cause a financial loss to the hospital, those who may benefit from specialized geriatric care, and those who may have lengthy inpatient stays or who may use more hospital resources than expected under a reasonable, anticipated course of treatment.

INTERVENTION

Once patients in need of geriatric care management are identified, they should be assigned a geriatric care manager who will coordinate their hospital stay.

Ideally, geriatric care managers will be registered nurses with experience in both geriatrics and care management who are skilled at building and maintaining good team relationships within a hospital. Their training should include principles of geriatric medicine and the application of care management techniques with the elderly; several months of on-the-job training with an experienced geriatric care management coach; and biannual continuing education seminars. The goal of this training should be to provide the hospital with highly trained and effective geriatric care managers.

Under the geriatric care management model, geriatric care managers are assigned to manage patients throughout their hospital stays. Each geriatric care manager can be assigned 15 to 20 patients. Geriatric care management intervention will vary substantially from patient to patient.

In general, geriatric care managers work to reduce hospital costs and lengths of stay by helping to improve hospital operational and administrative efficiencies (e.g., by seeing that broken equipment is repaired or that new laboratory or x-ray equipment is leased). In addition, geriatric care managers help smooth out the hospital discharge process by working closely with the patient, the family, the nursing staff, and the physician. Geriatric care managers serve as resources to physicians to help enhance care and to suggest alternative care settings, procedures, and solutions to problems.

PERFORMANCE EVALUATION

It is important to assess the effectiveness of a geriatric care management system. The hospital should be provided with quarterly performance reports that compare the hospital’s program with benchmark data prepared from the initial data analysis, as well as other regional and national normative data. These performance reports should track such data as number of Medicare patients managed, DRGs of patients managed, overall length of stay for managed patients, number of outliers, number of readmissions, available cost data on managed patients, and money saved as a result of the geriatric care management system.

The evaluation also may identify hospital inefficiencies that contribute to poor quality and increase Medicare patients’ lengths of stay. Inefficiencies may be quantified by patient and family satisfaction surveys, physician and nurse satisfaction surveys, morbidity/mortality reports, and reports tracking readmission rates.

ADDITIONAL BENEFITS

Most Medicare dollars are spent in the last six months of a patient’s life.(c) In addition to improving care and reducing costs for Medicare patients, an effective geriatric care management system can instill a geriatric care philosophy in the inpatient setting and thus facilitate realistic, effective planning for those patients who are admitted during the final six months of life. For these patients, a geriatric care management system should:

* Implement physician/family conferences where the physician, patient, and family discuss the type of care they envision for the final stage of the patient’s life;

* Communicate the agreed-upon care plan to all care providers who will have contact with the patient during this period;

* Incorporate advanced directives into all aspects of care planning;

* Encourage the formation of a bioethics committee at the hospital to resolve difficult ethical questions when they arise; and

* Provide ongoing education for geriatric care managers as well as hospital staff concerning all aspects of what constitutes appropriate, effective care during the final stage of life.

RESULTS OF SYSTEM IMPLEMENTATION

Significant savings may be achieved in hospitals that use geriatric care management systems. The results of one geriatric care management system operating in several hospitals over varying time periods (two to 20 months) have been quantified in inpatient days saved, and the results are shown in Exhibit 1. (Exhibit 1 omitted) From May 1991 through July 1993, one geriatric care management system saved a total of 15,448 patient days, or an average of 1.3 days per case managed (d). To date in 1993, the average days saved per case managed is 1.5. Exhibit 1 shows how well the geriatric care management system worked in selected diagnostic areas.

As shown in Exhibit 2, lengths of stay in these hospitals for patients not targeted or managed by the geriatric care management system increased 0.4 days, while lengths of stay for patients targeted and managed decreased 1.3 days. (Exhibit 2 omitted) The overall effect of the geriatric care management system in these hospitals has been a net decrease of 0.4 days in hospital length of stay.

SUMMARY

Factors that are critical for a geriatric care management system to work for hospitalized Medicare patients include:

* Strong administrative support from hospital staff members,

* Input from the nursing and medical staffs,

* Recruitment of experienced geriatric nurses with managed care experience,

* A hospital’s ongoing commitment to such a system and its goals, and

* The program’s integration into the hospital’s existing total quality management programs and adaptation to each hospital’s unique environment.

A geriatric care management system appears to be more successful in larger hospitals (those with at least 2,000 to 3,000 Medicare admissions per year) with significant financial problems and with a Medicare average length of stay of at least eight days.

 

ANALYSIS #1

The quality of medical care service is controlled in several ways. Evaluation are based on Customer Satisfaction.  There are watch dogs such as the coalition for Accountable Managed care and the center for Health care rights are concerned with patient’s rights as well as client satisfaction with services.  Manage Care put new doctor’s through certified process and a re-credentialing every 2 years, although the process is not always considered thorough.  There are several ways they collect standardized data from MCO’s and compiles it into the health plan employer data.  Six categories are: quality improvement, physician credentials, member’s right and responsibilities, preventive health services, utilization management and medical records are applied in evaluation on MCO.

 

One of the main issues I have found from researching several articles is patients not understand due to the fact of not being able to read.  65 years or older scored  a 1.  However because the test used in the poll did not include health related items, it is unclear how many elderly person can not read adequately to function in health setting.  So basically we have low literacy skills in the health care setting (i.e, poor ability to read and comprehend the things most commonly encountered in the health care setting, such as prescription bottles, appointment slips and informed consent forms.

 

Source Citation (MLA 7th edition) Managed Health Care Services :encyclopedia of emerging industries 5th ed Detroit: Gala virtual reference library web. 16 May 2016.

ANALYSIS #2

The article by Luft Harold attempts to analyze the different issues in managed care and provides possible solutions to the problems. In the article, managed care is defined as “a collection of health plans” (Harold, 2003) and the article relates these health care plans to both chronic and acute illnesses. Due to the vast amount of managed care plans though, quality of managed care is difficult to determine.

Later in the article, Harold discusses a few of the key points that determine quality of managed care. A few being the payment arrangements for physicians, provider networks offered by the plan, and “managerial approaches used by the plans to select clinicians. . . and encourage adherence to practice guidelines.” (Harold, 2003) With all the various factors that affect quality of managed care, Harold states that more projects are necessary to obtain and analyze information on managed care, and will thus provide a better overview of managed care. Overall, a project similar to the Human Genome Project except relating to managed care, will not only be of interest to the “study of managed care, but [also] to issues of quality measurement, patient and consumer surveys, and complex study designs.” (Harold, 2003)

Managed care has various impacts on different health care settings, but the most apparent are in the costs of treatment and how physicians treat their patients. Managed care plans have a direct effect on the cost of treatment, lowering the cost of treatments and helping America save money on healthcare. Physicians though can be negatively affected, forcing them to treat more patients rather than maintain quality care for their patients. Managed care can also restrict physicians, forcing them to obtain approval before proceeding with treatment. Patients too are affected by managed care, since they are restricted to what types of medical providers they can go to and can be required to obtain preauthorization when going to an emergency room. Managed care can also force patients with mental illnesses to have a more difficult time obtaining treatment than a patient with a physical illness. Overall, managed care is cost effective, but both physicians and patients are being negatively affected, restricting both physicians and patients in the options available to them.