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health maintenance organization

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The comeback of the HMO


The much maligned (and over-maligned) health maintenance organization (HMO) is making a comeback, under  pressure from private and public payers to save money while seeking better medical outcomes, The New York Times reports.

The Times notes that “A  defining feature of an HMO is  the restriction placed over which doctor or hospital a patient can use, which was a primary reason so many floundered in the 1990s. Doctors and patients complained about their lack of choices. Critics also accused the plans of denying patients tests and procedures to save money, and many plans were seen as offering low-quality care.”

But, The Times reports: “Despite the stigma and many failed efforts, insurers say they are eager to push a revamped version that revives many of the same features that restrict choices as a way of lowering costs. Insurers are already promoting HMO’s on the state exchanges created under the federal health law, and many are trying to persuade more companies and their employees to sign up.”

Putting more patients into narrower provider networks is  crucial to bringing America’s astronomical health care under contr0l.

Medicare Advantage plans: Which perform best


FierceHealthPayer looks at a McKinsey & Co. report on the 2016 Medicare Advantage (MA) Star Ratings  to see what’s working best.

The main cause of these better marks is improved plan performance, not CMS changes to cut-points, measures or methodology. “While the report notes that changes to certain individual measures did influence the ratings of some plans, overall the scoring changes largely canceled each other out.”

Other findings from the report, as summarized by FierceHealthPayer, include:

  • “Although health maintenance organization plans outperformed the market in previous years, preferred provider organization plans ranked highest this year.
  • “Plans built around integrated delivery networks (in particular, Kaiser Permanente) received a higher weighted average rating than plans offered by commercial carriers or Blues carriers. But commercial and Blues carriers continue to close the gap, the report notes.
  • “Medicare Advantage plans with more members tended to do better, as the 2016 enrollment-weighted average star ratings are lower for carriers with fewer than 20,000 M.A. members than for carriers with M.A. enrollment between 20,000 and 100,000 or plans with more than 100,000 members.”

Healthcare ‘management by process’


This HealthAffairs blog entry  by John Toussaint discusses  the ThedaCare Center for Healthcare Value‘s framework for transforming healthcare delivery through improvement-management techniques similar to the “management by process” espoused by Edwards Deming in the 1980s.

The framework has many  principles from  such big manufacturers as Toyota— now being applied to healthcare— using the “concepts of Plan-Do-Study-Act (PDSA) thinking, developing model cell areas to test new concepts, spreading new processes, and building new sets of standards for leadership and daily management.”

A “model cell” is a place, “usually a clinic or a department, where care is completely redesigned. The process change leads to new roles and responsibilities for everyone involved.”

An example: “At the Palo Alto Medical Foundation, in California, there was a need to deliver a better patient service experience while reducing cost.

“A well-known health maintenance organization (HMO) was aggressively competing with Palo Alto with better quality at a lower cost, so the organization’s leaders began model cell work in one clinic in Fremont, Calif. They eliminated doctors’ private offices, developed dyads between doctors and medical assistants, started two-minute morning huddles to understand demand for the day, and in one year, completely redesigned the entire outpatient experience. ”

Mr. Toussaint also looked at MemorialCare, in Long Beach, Calif., where a group of “specially trained facilitators teach the management team how to be successful ‘lean’ managers. This is not training in a classroom with PowerPoint slides. Instead, it is applying principles and tools to the real work; where value is created for the patient at the bedside.

“Facilitators train leaders in ‘visual management,’ which involves setting up visual management boards, identifying and posting key metrics that relate to performance of the department, and encouraging staff to post ideas for improvement. Managers are also trained to teach frontline staff to identify and solve problems, and how to map processes of care to understand which steps in the process are non-value-added to the patient.”





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