An Analysis of the Managed Competition Act.

"April 1994"--Cover.

2016 Quarter 2 Managed Care Ombudsman Program Quarterly Report

This report provides an update on the following items for the first programmatic quarter (July, August and September 2016): • 2nd Quarter Overview • Systemic Trends • Community Partnerships and Outreach • Managed Care Ombudsman Program Administrative Update

2016 Quarter 1 Managed Care Ombudsman Program Quarterly Report

he Managed Care Ombudsman Program provides various services including education and information regarding managed care plans, services, care and processes, advocacy and outreach on behalf of members, and appeals assistance and complaint resolution for members needing assistance with resolving issues with their managed care plan or navigating the managed care system. This report provides an update on the following items for the first programmatic quarter (April, May and June 2016): • 1st Quarter Overview • Systemic Trends • Community Partnerships and Outreach • Managed Care Ombudsman Program Administrative Update

Review of Program Integrity Operations At Six Managed Care Organizations Delivering Medicaid Services under a Contract with the South Carolina Department of Health & Human Services

The State contracted with six managed care organizations to deliver Medicaid managed care at an annual cost of $2.7 billion, representing 10% of the State’s annual budget, to 750,000 Medicaid beneficiaries in South Carolina. This review’s scope and objectives were: Test the six MCOs’ compliance and effective execution of the SCDHHS’s managed care contract “Section 11 - Program Integrity” focusing on the operational components of pre-payment review and post-payment review. Identify opportunities to improve SCDHHS’s biennial managed care contract, contract monitoring, and MCO compliance and effective execution of the contract.

Treatment intensification and risk factor control: toward more clinically relevant quality measures.

BACKGROUND: Intensification of pharmacotherapy in persons with poorly controlled chronic conditions has been proposed as a clinically meaningful process measure of quality. OBJECTIVE: To validate measures of treatment intensification by evaluating their associations with subsequent control in hypertension, hyperlipidemia, and diabetes mellitus across 35 medical facility populations in Kaiser Permanente, Northern California. DESIGN: Hierarchical analyses of associations of improvements in facility-level treatment intensification rates from 2001 to 2003 with patient-level risk factor levels at the end of 2003. PATIENTS: Members (515,072 and 626,130; age >20 years) with hypertension, hyperlipidemia, and/or diabetes mellitus in 2001 and 2003, respectively. MEASUREMENTS: Treatment intensification for each risk factor defined as an increase in number of drug classes prescribed, of dosage for at least 1 drug, or switching to a drug from another class within 3 months of observed poor risk factor control. RESULTS: Facility-level improvements in treatment intensification rates between 2001 and 2003 were strongly associated with greater likelihood of being in control at the end of 2003 (P < or = 0.05 for each risk factor) after adjustment for patient- and facility-level covariates. Compared with facility rankings based solely on control, addition of percentages of poorly controlled patients who received treatment intensification changed 2003 rankings substantially: 14%, 51%, and 29% of the facilities changed ranks by 5 or more positions for hypertension, hyperlipidemia, and diabetes, respectively. CONCLUSIONS: Treatment intensification is tightly linked to improved control. Thus, it deserves consideration as a process measure for motivating quality improvement and possibly for measuring clinical performance.

The Affordable Care Act and the Transformation of US Health Care

The neoliberal period was accompanied by a momentous transformation within the US health care system.  As the result of a number of political and historical dynamics, the healthcare law signed by President Barack Obama in 2010 ‑the Affordable Care Act (ACA)‑ drew less on universal models from abroad than it did on earlier conservative healthcare reform proposals. This was in part the result of the influence of powerful corporate healthcare interests. While the ACA expands healthcare coverage, it does so incompletely and unevenly, with persistent uninsurance and disparities in access based on insurance status. Additionally, the law accommodates an overall shift towards a consumerist model of care characterized by high cost sharing at time of use. Finally, the law encourages the further consolidation of the healthcare sector, for instance into units named “Accountable Care Organizations” that closely resemble the health maintenance organizations favored by managed care advocates. The overall effect has been to maintain a fragmented system that is neither equitable nor efficient. A single payer universal system would, in contrast, help transform healthcare into a social right.

Impact on hip fracture mortality after the establishment of an orthogeriatric care program in a colombian hospital

El objetivo del estudio es evaluar la mortalidad a un año en pacientes con fractura de cadera, mayores de 65 años tratados en un programa establecido de orto-geriatría. 298 se trataron de acuerdo al protocolo de orto-geriatría, se calculo la mortalidad a un año, se establecieron los predictores de mortalidad orto-geriátrico. La sobrevida anual se incremento de 80% a 89% (p = .039) durante los cuatro años de seguimiento del programa y disminuyo el riesgo de mortalidad anual postoperatorio (Hazard Ratio = 0.54, p = .049). La enfermedad cardiaca y la edad maor a 85 años fueron predictores positivos para mortalidad.

An ecology of centre-based child care

The studies in the thesis were derived from a program of research focused on centre-based child care in Australia. The studies constituted an ecological analysis as they examined proximal and distal factors which have the potential to affect children's developmental opportunities (Bronfenbrenner, 1979). The project was conducted in thirty-two child care centres located in south-east Queensland. Participants in the research included staff members at the centres, families using the centres and their children. The first study described the personal and professional characteristics of one hundred and forty-four child care workers, as well as their job satisfaction and job commitment. Factors impinging on the stability of care afforded to children were examined, specifically child care workers' intentions to leave their current position and actual staff turnover at a twelve month follow-up. This is an ecosystem analysis (Bronfenbrenner & Crouter, 1983), as it examined the world of work for carers; a setting not directly involving the developing child, but which has implications for children's experiences. Staff job satisfaction was focused on working with children and other adults, including parents and colleagues. Involvement with children was reported as being the most rewarding aspect of the work. This intrinsic satisfaction was enough to sustain caregivers' efforts to maintain their employment in child care programs. It was found that, while improving working conditions may help to reduce turnover, it is likely that moderate turnover rates will remain as child care staff work in relatively small centres and they leave in order to improve career prospects. Departure from a child care job appeared to be as much about improving career opportunities or changing personal circumstances, as it was about poor wages and working conditions. In the second study, factors that influence maternal satisfaction with child care arrangements were examined. The focus included examination of the nature and qualities of parental interaction with staff. This was a mesosystem analysis (Bronfenbrenner & Crouter, 1983), as it considered the links between family and child care settings. Two hundred and twenty-two questionnaires were returned from mothers whose children were enrolled in the participating centres. It was found that maternal satisfaction with child care encompassed the domains of child-centred and parent-centred satisfaction. The nature and range of responses in the quantitative and qualitative data indicated that these parents were genuinely satisfied with their children's care. In the prediction of maternal satisfaction with child care, single parents, mothers with high role satisfaction, and mothers who were satisfied with the frequency of staff contact and degree of supportive communication had higher levels of satisfaction with their child care arrangements. The third study described the structural and process variations within child care programs and examined program differences for compliance with regulations and differences by profit status of the centre, as a microsystem analysis (Bronfenbrenner, 1979). Observations were made in eighty-three programs which served children from two to five years. The results of the study affirmed beliefs that nonprofit centres are superior in the quality of care provided, although this was not to a level which meant that the care in for-profit centres was inadequate. Regulation of structural features of child care programs, per se, did not guarantee higher quality child care as measured by global or process indicators. The final study represented an integration of a range of influences in child care and family settings which may impact on development. Features of child care programs which predict children's social and cognitive development, while taking into account child and family characteristics, were identified. Results were consistent with other research findings which show that child and family characteristics and child care quality predict children's development. Child care quality was more important to the prediction of social development, while family factors appeared to be more predictive of cognitive/language development. An influential variable predictive of development was the period of time which the child had been in the centre. This highlighted the importance of the stability of child care arrangements. Child care quality features which had most influence were global ratings of the qualities of the program environment. However, results need to be interpreted cautiously as the explained variance in the predictive models developed was low. The results of these studies are discussed in terms of the implications for practice and future research. Considerations for an expanded view of ecological approaches to child care research are outlined. Issues discussed include the need to generate child care research which is relevant to social policy development, the implications of market driven policies for child care services, professionalism and professionalisation of child care work, and the need to reconceptualise child care research when the goal is to develop greater theoretical understanding about child care environments and developmental processes.

Improving self care of patients with chronic disease using online personal health record

BACKGROUND: Effective management of chronic diseases such as prostate cancer is important. Research suggests a tendency to use self-care treatment options such as over-the-counter (OTC) complementary medications among prostate cancer patients. The current trend in patient-driven recording of health data in an online Personal Health Record (PHR) presents an opportunity to develop new data-driven approaches for improving prostate cancer patient care. However, the ability of current online solutions to share patients' data for better decision support is limited. An informatics approach may improve online sharing of self-care interventions among these patients. It can also provide better evidence to support decisions made during their self-managed care. AIMS: To identify requirements for an online system and describe a new case-based reasoning (CBR) method for improving self-care of advanced prostate cancer patients in an online PHR environment. METHOD: A non-identifying online survey was conducted to understand self-care patterns among prostate cancer patients and to identify requirements for an online information system. The pilot study was carried out between August 2010 and December 2010. A case-base of 52 patients was developed. RESULTS: The data analysis showed self-care patterns among the prostate cancer patients. Selenium (55%) was the common complementary supplement used by the patients. Paracetamol (about 45%) was the commonly used OTC by the patients. CONCLUSION: The results of this study specified requirements for an online case-based reasoning information system. The outcomes of this study are being incorporated in design of the proposed Artificial Intelligence (Al) driven patient journey browser system. A basic version of the proposed system is currently being considered for implementation.

Physical activity levels among children attending family day care

Objective To objectively measure the physical activity (PA) levels of children attending family day care programs. Methods A total of 114 children from 47 family day care centers wore an accelerometer for the duration of their time in care. Time in moderate-to-vigorous PA (MVPA) and total PA was calculated using previously validated cut points. Results Children accumulated 5.8 ± 3.2 minutes of MVPA and 10.4 ± 4.4 minutes of total PA per hour of attendance. Boys exhibited significantly higher levels of PA than girls. Among healthy weight children, 4- and 5-year-olds exhibited significantly higher levels of PA than 2- and 3-year-olds. Overweight and obese 4- and 5-year-olds exhibited significantly lower levels of PA than their healthy weight counterparts. Conclusions and Implications Children attending family day care participate in low levels of PA during the child care day. The results highlight the need for effective programs to promote PA in family day care.

Challenges in improving chronic disease survivorship outcomes using tele-health and self-managed online solutions

The advances in modern information and communication (ICT) technology continue to address the challenges and improve` health outcomes for the survivors of chronic disease such as prostate cancer. The management of survivorship is increasingly becoming an important need for the survivors to manage their chronic conditions. The technology interventions such as tele-health as well as self-managed technology applications have shown a potential to improve survivorship outcomes. However, the application of these tools should be supported by strong health economics evidence. This work discusses the challenges of technology led survivorship care models and presents an integrated approach to address these challenges.

The birthday cake: Social relations and professional practices around mealtimes with toddlers and child care

Events that involve food and eating are important parts of the daily routine in which adults and children participate in child care settings. These events can be viewed as cultural practices because they involve certain everyday ways of acting, thinking or feeling (Grusec JE et al, Child Dev 71(1): 205–211, 2000). The cultural practices around food and eating symbolise and guide the social relations, emotions, social structures and behaviours of the participants. Identities and roles for the participants are created in these practices, marked by ambiguity, movement and fluidity through ongoing processes of negotiation (Punch S et al, Child Geogr 8(3): 227–232, 2010). The formal professional systems that guide these practices in early education and care programs often focus on the nutritional value of the food, while the children and teachers involved in these mealtime events account for the intersubjective experiences. Mealtimes provide opportunities for children and teachers to interact and co-construct meaning around the situations that arise. Of special interest in this research are teachers’ and children’s intentions for communication in the context of events involving food and eating and the kind of learning embedded in the communications that occur. Throughout this chapter, these events are referred to as mealtimes. This study is informed by phenomenological theory which aims to reach understandings about interactions and their meaning from the perspective of the participating individuals.

Development of a Complex Intervention for Secondary Prevention of Coronary Heart Disease in Primary Care Using the UK Medical Research Council Framework

Objective: To apply the UK Medical Research Council (MRC) framework for development and evaluation of trials of complex interventions to a primary healthcare intervention to promote secondary prevention of coronary heart disease. Study Design: Case report of intervention development. Methods: First, literature relating to secondary prevention and lifestyle change was reviewed. Second, a preliminary intervention was modeled, based on literature findings and focus group interviews with patients (n = 23) and staff (n = 29) from 4 general practices. Participants’ experiences of and attitudes toward key intervention components were explored. Third, the preliminary intervention was pilot-tested in 4 general practices. After delivery of the pilot intervention, practitioners evaluated the training sessions, and qualitative data relating to experiences of the intervention were collected using semistructured interviews with staff (n = 10) and patient focus groups (n = 17). Results: Literature review identified 3 intervention components: a structured recall system, practitioner training, and patient information. Initial qualitative data identified variations in recall system design, training requirements (medication prescribing, facilitating behavior change), and information appropriate to the prospective study participants. Identifying detailed structures within intervention components clarified how the intervention could be tailored to individual practice, practitioner, and patient needs while preserving the theoretical functions of the components. Findings from the pilot phase informed further modeling of the intervention, reducing administrative time, increasing practical content of training, and omitting unhelpful patient information. Conclusion: Application of the MRC framework helped to determine the feasibility and development of a complex intervention for primary care research.