Move Medicare patients into managed care?
Managed care costs are rising slower than Medicare costs. The nation’s total spending for health care increased 5.5% in 1995 to nearly $1 trillion, an average of $3,620 per person. The fact that spending grew faster for Medicare than for the private sector may strengthen the argument for the need to move more Medicare patients into managed care. t
Managed care adjusting to its environment
Three late developments seem evidence of some reality-testing on the part of managed care companies.
The gatekeeper era in managed care may be winding down. Many HMOs are trying to simplify and speed things up by easing referral restrictions for specialists. Whether easier access to specialists will be followed by higher costs remains to be seen. Betting on that eventuality, some HMOs are charging up to 15% more in premiums for plans that allow direct access to specialists.
Also, Empire Blue Cross and Blue Shield of New York says it’s gearing up to allow independent third-party reviews of its coverage of experimental treatments for terminally ill patients. The Medical Ombudsman Program and the Emergency Care Research Institute, neither of which have ties to managed care or insurance industries, will act as reviewers. Empire will pay for and be bound by the reviews. A similar law requiring such reviews was enacted in California in October of last year.
And finally, managed care plans may begin covering ED visits for patients with "reasonable" concern. Coverage would be based on symptoms, not diagnosis. For example, the person with chest pains would be allowed a reimbursable ED visit. t
Redux: Big business, big problems
The widespread American quest for thinness is creating far-reaching health risks.
QI and ED personnel should be aware that patients could be taking one of the popular weight-loss drugs when they come to the hospital and not think it important enough to mention. Dexfenfluramine, the active ingredient in Redux, and fenfluramine, used in related medications, have side effects including pulmonary hypertension and edema. Risk may rise if a patient takes the drug for longer than three months. Watch out for those and other complications, as well as interactions with other drugs patients may be taking.
Even though Redux has been on the market for only a little more than half a year, more than 1.2 million prescriptions have been written and sales total more than $20 million a month. Aggressive, broad-based marketing got it there, but, say doctors, some serious health risks of the fat fighter are underplayed.
The FDA approved Redux a year ago for use by "morbidly obese" patients those overweight by at least 20% to 30%. Despite that prescriptive, the manufacturer pitches the product broadly to the public, and to gynecologists and psychiatrists, to whom the patient concerned about overweight typically turns.
Following are names and telephone numbers of sources quoted in this issue:
• Indun Whetsell, RN, quality improvement coordinator at the Regional Medical Center of Orangeburg and Calhoun Counties, Orangeburg, SC. Telephone: (803) 533-2688.
• Jayne Bassler, RN, quality manager at Volusia Medical Center, Orange City, FL. Telephone: (904) 851-5263.
• Patrice Spath, ART, BA, consultant in health care quality and resource management, Forest Grove, OR. Telephone: (503) 357-9185.
• Dennis S. O’Leary, MD, president of the Joint Commission on Accreditation of Healthcare Organizations, Oakbrook Terrace, IL. Telephone: (630) 792-5000.
• Karen Reeves, RN, vice-president of professional services for South Carolina Hospital Association, Columbia, SC. Telephone: (803) 796-3080.
• Michelle Bell, assistant vice-president of Memorial Hospital-Memorial City, Houston. Telephone: (713) 932-3000.
• Jerod Loeb, PhD, director of research and evaluation, Joint Commission on Accreditation of Healthcare Organizations, Oakbrook Terrace, IL. Telephone: (630) 792-5000.
• Sharon Baschon, utilization management consultant in Durham, NC. Telephone: (919) 383-1108.
• Michael Smolensky, MD, professor in the School of Public Health at the Health Sciences Center of the University of Texas-Houston, Houston. Telephone: (713) 500-4472.
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