Fairleigh DickinsonExecutive MBAHealth Systems .ppt

Fairleigh DickinsonExecutive MBAHealth Systems Management Managed Care and Provider Reimbursement Robert Eidus MD, MBA May 31 Final Exam (First Hour) Case Study- Merck- Medco: Ken Population Based Health Management Preventive Health Services in Managed Care Demand Management Disease Management Case Management Case Study- Accordant Health Services- Araceli Oral Presentations of Project Wrap Up and Feedback Case Study Merck-Medco Managed Care: Ken Population Based Health Management Key Premise Different populations have different needs/ risks/ health cost exposure Strategies should be tailored to sup-population needs Population based health management Population based health management Preventive Health Services Why do this if you are in managed care? Historical Roots (except Medicare) Societal Expectations Marketing Risk Selection You are graded on this Why not do preventive services? Time to benefit is greater than member retention Member turnover can be as high as 35% per year Cost of management services and cost of testing Lack of clarity on what preventive services should be promoted Examples of managed care success stories in prevention Mammography Pediatric immunizations Cholesterol Screening Adult immunizations Beta blockers after MI (tertiary prevention) ACE inhibitors in diabetics (secondary prevention) Colorectal cancer screening Kaiser US Healthcare Examples of un-success Screening for depression Why? Typical Prevention Interventions Registries Reminders Educational activities Provider incentives Barriers to effective managed care preventive efforts Migrating membership Inaccurate data bases Lack of point of service effectiveness Missed opportunities Physician overload Lack of systems in providers offices Demand Management Basic Principle: 70% of illness is self limited Much of primary care visits and ER visits are patient initiated; very often due to lack of education/ information Giving patients information/ advice/ and alternative venues for care