Managed care program


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  • The Centers for Disease Control and Prevention (2010) reported that 7 out of 10 deaths among Americans are due to chronic illness which can be prevented. It further reported that 43 million American adults smoke, and 20 percent of high school students are smokers in 2007 survey. Tobacco use annual costs is $75 billion and obesity is $61 billion (Kongstvedt, 2007). Chronic diseases contribute to the high health care costs and spending in the United States.
  • Preventive measures such as exercise, cancer screening, hypertension treatment, and smoke free environment can decrease mortality rates by 20 to 60 percent (Kongstvedt, 2007). The delay in implementing wellness and prevention programs will have a catastrophic effect on the health of the population and the economy due to the rising health care costs of caring for individuals with chronic diseases and the eventual needs of baby boomers.
  • DM implemented by MCOs has been proven to lower costs. DM has the ability to support the physicians and patients relationship in planning for their care, focus on prevention and wellness using evidenced-based practice guidelines, patient centered care, and it can evaluate clinical and economic outcomes continually to improve the total overall health of its members.
  • Patel et al (2009) reported that behavioral programs such as in the workplace or hospitals and using different ways of communication such as telephone counseling, internet, and in groups evolved due to the effects of smoking on public health. Terry et al (2010) also reported that smoking cessation programs will be successful based on past experiences. Smoking cessation program provides the individual the entire process of quitting which is personalized.
  • Payment to physicians by MCOs depends if they implement quality improvement for the care of patients. MCOs can provide physicians indicators services or reminders for patients to schedule appointments.
  • The AQA released 26 health care quality indicators in response to the United States’ Healthy People 2010 initiative to reduce smoking prevalence to less than 12 percent in adults and 16 percent in youth (AIM, 2007, p.IIc2-12).
  • Case management is a complicated task that requires a person to have a strong personality that knows everything from clinical, peper works, to dealing with physicians and patients. There are so many challenges and responsibilities involved including financial, legal, and the need to meet the goals of the program. This is where plans on how to achieve the goal of total smoking cessation will be realized.
  • Smoking cessation program needs a community case manager to educate the community about the program of a smoke free environment. The case manager should collaborate with physicians towards a coordinated task of counseling, encourage the use of medication to help quit, and provide resources such as a state-based quitline services. (CDC, 2010).
  • The different health care facilities are part of community involvement towards achieving the goal of prevention and wellness.
  • The three criteria for quality are the foundation of evaluating the overall performance of the organization.
  • The three Donabedian criteria are still in use but the new trend now are the quality improvement aims of IOM.
  • MCOs have MedCo that facilitate prescription mail-order which is a cost saving vehicle to save on drug copayments. Brand names are also changed to generics that are the same but much cheaper.
  • Pharmacy benefit providers should be able to manage costs, access to medications, and has excellent customer support program (Kongstvedt, 2007).
  • The federal government are giving incentives to health care organizations to implement EMR to reduce health care costs, improve safety, reduce deaths due to medical errors, and improve quality health care.
  • Managed care program

    1. 1. MANAGED CARE PROGRAM SMOKING CESSATION Polly C. Tamayo MHA 628 Professor Ona Johnson November 28, 2011
    2. 2. Smoking Cessation Program Chronic diseases are the leading cause of death in the United States Heart disease, stroke, cancer, diabetes, and arthritis are costly and preventable (CDC, 2010) Tobacco use, physical inactivity, poor nutrition, and excessive consumption of alcohol are risk factors that lead to chronic disease
    3. 3. The Role of Preventing Disease Many studies show that prevention can decrease chronic disease by eliminating risk factors (Kongstvedt, 2007) Rising health care costs are affecting the Americans’ access to health care and the economy Interventions for chronic diseases are costly (Russell, 2009)
    4. 4.  Disease management (DM) as defined by DMAA is a “system of coordinated health care interventions and communications for populations with conditions in which patient self-care efforts are significant (Kongstvedt, 2007) Managed care organizations (MCOs) implemented DM to their members to lower the costs of care, improve access, and improve quality health care DM programs (DMP) should have six components to be considered a full service DM program (Kongstvedt, 2007)
    5. 5. Patient Incentives Smoking is “among the leading causes of premature mortality and preventable death in the U. S.” as reported by CDC (Patel, Larson, Hong, Brown & Hargreaves, 2009, p. 933) Research showed that there was a decrease of smoking rates from 41.2 percent in 1965 to 20.8 per cent in 2004 (Terry, Seaverson, Staufacker, & Tanaka, 2010) Counseling, pharmacotherapy, and telephone-based counseling improved success of quitting smoking (Terry et al, 2010) Cash or gift certificates are given for participants and additional award to complete the program Patient satisfaction since expenses incurred will be reimbursed by the health plan Discounts on fitness centers and weight management programs.
    6. 6. Physician Incentives MCOs reward physicians or clinics who implemented quality improvement and preventive programs (Kongstvedt, 2007) Performance feedback from claims data helps physicians to be informed of their patients’ preventive services Implementation of electronic health records (EMR/EHR) can improve communications between MCOs , providers, and patients. MCO’s pay-for-performance programs give incentives to provide the best quality health care and document patient outcomes (Kongstvedt, 2007)
    7. 7. Physician Incentives The Ambulatory Care Quality Alliance (AQA, 2007) released 26 health care quality indicators for clinicians to use in improvement efforts which include measures relating to smoking cessation. Reimbursement adjustments and bonus payments are MCO’s incentives for physicians meeting quality health care
    8. 8. Case Management Defined as a “collaborative process that assesses, plans, implements, coordinates, monitors, and evaluates the options and services required to meet an individual’s health needs, using communication and available resources to promote quality, cost effective outcomes” (Kongstvedt, 2007) Case manager works to communicate to the different healthcare professionals, health plans, and should have strong clinical expertise. In smoking cessation program, the case manager should focus on the patient’s overall management from the start to the time that patient quit smoking.
    9. 9. Case Management The community case management program is to provide patients “access to medical, social, financial, educational, and other services to meet the basic needs of living day to day” (Kongstvedt, 2007, p. 263). In prevention and wellness program, the case manager is responsible to review patient records and progress, review quality issues, visit and follow up, and talk to patient and family members about the plan of care.
    10. 10. Facilities Hospitals, medical groups, and physician offices should be given incentives if their employees participate in the smoking cessation program Counseling visits, coverage for nicotine cessation medications , preventive services, immunizations and screening should be part of member benefits to increase access to these facilities (Kongstvedt, 2007). Behavioral health care services should be included in the smoking cessation program to counsel participants to change their lifestyle.
    11. 11. Quality of Care There are three criteria used for assessment of quality: structure, process, and outcome by Donabedian (Kongstvedt, 2007). Structure are the qualifications of physicians. and personnel, licensure of facilities, compliance of safety codes, record keeping, and physician network appointments (Kongstvedt, 2007). Process criteria is the way care is provided such as preventive health screening, and follow up of critical lab results
    12. 12. Quality of Care Outcome criteria are the overall result of the treatment or service such as infection rates, morbidity, and mortality (Kongstvedt, 2007). Continuous improvement process model is the modern quality program based on “fundamentals of quality assurance, incorporates the improvement aims of the Institute of Medicine (IOM), and is responsive to the changing marketplace”(Kongstvedt, 2007, p.340). Prevention such as smoking cessation program should have a quality assurance program in place to provide quality of care to participants.
    13. 13. Prescription Benefits Prescription drug program are part of MCO’s member benefits including Medicaid programs and Medicare Part D (Kongstvedt, 2007). Employers should look and study into their prescription drug benefit to be able to obtain the most effective pharmacy benefit program (PBP) (Kopenski, 2008). The PBP design should include three factors:” multiple delivery channels, complex provider contracting, and a vast range of drug products “(Kopenski, 2008, p.7)
    14. 14. Prescription Benefits MedCo has services besides mail-order such as giving information if the different prescription medications do not react with each other. Employers should choose a PBP best suited to all employees which has low copayments, and provide extra services to members such as drug information “Aligning all aspects of pharmacy benefit is the best and only way to help control drug benefit costs and at the same time promote greater employee satisfaction” (Kopenski, 2008, p.11).
    15. 15. The Future of Data Use and Informatics The use of information technology will enhance data collection, research, and development in managed care Claims data will be used in the future for further research and development to study and improve quality health care. The implementation of EMR not only in hospitals but also physician offices, MCOs will be able to monitor utilization trends and costs of health care (Kongstvedt, 2007). For smoking cessation program, access to health plans educational materials will be easy through the internet.
    16. 16. Conclusion Chronic disease is the leading cause of death which is costly and considered to be preventable. Managed care organizations are implementing disease management programs to prevent chronic disease. Risk factors such as tobacco use, inactivity, poor nutrition and excessive alcohol consumption should be resolved. Smoking cessation programs will be successful with the support of family, providers, health plans, other health care professionals, and the state and federal government
    17. 17. ReferencesAIM. (2007). Practice improvement, Annals of Internal Medicine, 146(3), Retrieved from for Disease Control and Prevention. (2010). Chronic diseases and health promotion, Atlanta, GA, Retrieved from, P. (2007). Essentials of Managed Health Care 5th edition, Sudbury, MA. Jones and Bartlett.Kopenski, F. (2008). Prescription drug benefit design: the building blocks and their impact on cost, Benefits Quarterly, 24(4), p. 7-11, Retrieved from
    18. 18. ReferencesPatel, K., Schlundt, D., Larson, C., Hong, W., Brown, A., & Hrgreaves, M. (2009). Chronic illness and smoking cessation, Nicotine and Tobacco Research, 11(8), p. 933-939, Retrieved from, L. (2009). Preventing chronic disease: an important investment, but don’t count on cost savings, Health Affairs, 28(1), p. 42-45, Retrieved from http://www.ebscohost.comTerry, P., Seaverson, E., Staufacker, M., & Tanaka, A. (2011). The effectiveness of telephone-based tobacco cessation program offered as part of a worksite health promotion program, Population Health management, 14(3), p.117-125, Retrieved from http://www.