The Journal of ambulatory care management
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This article examines the field of outcomes research from the perspective of a managed care organization, The Fallon Healthcare System, currently involved in many different types of studies. Outcome studies are characterized by the types of questions they examine. The cost and labor implications for each category are examined. Finally, a partnership among different participants in the outcome research field, including managed care organizations, academic institutions, and pharmaceutical companies, is proposed.
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A new "episode of care" definition of emergency care was developed, consisting of the emergency department encounter and all subsequent, related care delivered within 48 hrs from the initial contact. Data were analyzed by ICD-9-CM Major Diagnostic Category (MDC) and surgical intervention using 1.6 million episodes generated by 809,145 separate patients from a national claims database. ⋯ For several MDCs, hospitalization and/or surgical procedures were also major determinants of overall episodic charges. Results support the premise that economic analysis and reimbursement of emergency care benefits from the use of episodic data.
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Medicaid spending is an increasing burden on already stressed state budgets. The states find themselves trapped between these growing costs and mounting pressure to ensure access of the underserved to health care services. ⋯ Nevertheless, there have been some successes and, clearly, Medicaid managed care has potential. The unanswered question is the extent to which states can meet the diverse challenges of both Medicaid and managed care and tap that potential.
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EDs are the access of last resort for many Americans, and cost-driven reform initiatives that restrict ED utilization could deter people from seeking necessary and timely medical services. The experience in Canada under universal coverage suggests that major reform could lead to a substantial increase in ED utilization, especially in view of the relative shortage of primary care physicians in the United States. ⋯ Integration of emergency services into comprehensive health delivery systems under the concept of managed competition is essential to ensure access and cost-effective delivery of services. The hospital ED may well serve as an important focal point in the development of alternative physician-hospital relationships.