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Managed care fear not.

The evolution of managed care really began during World War II when a shipbuilding company, Kaiser, developed a health care plan for employees. The health care plan provided a continuum of care from prevention to acute care with its own providers at a low cost to employees. This was ingenious because other employers were paying insurance premiums without having any control over costs.

The Hill-Burton Act of 1946 provided federal grants and loans for the building of hospitals. By 1982 there were more than 1 million community hospital beds reimbursed at cost, which was determined by the hospitals (Rice, 1990). In 1984, inpatient hospital costs amounted to $ 158 billion and remain the largest health care expenditure (Rice, 1990).

Hospital Cost-Containment

Hospital cost containment is fairly recent with the enactment of the Social Security Amendments of 1983, which established the Medicare prospective payment system of diagnosis related groups (DRGs) and peer review organizations (PROs). Hospitals are reimbursed per discharge based on a predetermined fixed rate, thereby providing the impetus to decrease hospital stay days. Private insurance rapidly joined the federal government's attempt to decrease inpatient costs with the inception of reasonable and customary contracted prices per patient day.

In addition, hospitals are required to contract with a PRO in order to be paid. PROs review cases for DRG appropriateness, quality of care, admission, and discharge processes. Thus, PROs were the first form of utilization review.

The first hospital to develop a plan for cost-effective care was the New England Medical Center in the early 1980s. The New England Medical Center is credited with pioneering nursing case management and critical pathways to ensure discharge within DRGs for reimbursement (Zander, 1994). Critical pathways depict structured care processes for various diagnoses. Nurse case managers coordinate and monitor the critical pathway collaboratively with the interdisciplinary team and family (Zander, 1994).

Employers' demand for affordable health insurance has increased enrollment of employees in managed care plans such as health maintenance organization, preferred provider organizations, or point of service plans. These plans are able to control cost by management of health care utilization, quality, and delivery (Coeur, 1996). Managed care plans have shifted the disease focus of the medical marketplace to wellness and prevention. However it is estimated based on nationwide surveys that one-fourth of children and one-third of adults have a chronic disease.

Case Management: An Emerging Specialty

Managed care plans have successfully provided cost-effective care to chronic illness enrollees through an aggressive case management system. Last year Aetna Health Plans and the Individual Case Management Association presented case management practice guidelines for optimal patient outcomes (Coeur, 1996). The guidelines promote a continuum of care that integrates plan benefits and community resources to avoid frequent hospitalization. Case managers are responsible for the case management process of assessment, planning, implementation, coordination and evaluating of health-related service options (Coeur, 1996).

Case management is an emerging specialty in nursing. There are five professional associations related to case management with more than 6,000 nurse members: American Association for Continuity of Care, Association of Medical Case Managers, Association of Rehabilitation Nurses, the Case Management Society of America, and the Certified Insurance Rehabilitation Specialist Commission. The philosophy of case management has been incorporated into undergraduate baccalaureate programs and is a major in three graduate nursing programs.

Several case management evaluation studies have been conducted that demonstrate improved quality of life and reduced costs, primarily in the mentally ill and the elderly (Franklin, 1987; Kemper, 1988). Pediatric case management evaluation studies found are related to high-risk pregnancies. Korenbrot, Showstack, Loomis, and Brindis (1989) conducted a descriptive comparative study of 411 teens who received case management as part of a comprehensive health care program. Case management was attributed to reducing low birth weight. Significantly more pediatric case management evaluation studies are needed to explore the outcomes for children with special needs. In response to the need for a national standard for measurement of case management outcomes, the Case Management Society of America has established the Center for Case Management Accountability to conduct a study on performance measurements of case management (CMSA, 1996).

Currently more than 23% of all Medicaid recipients, primarily children, are enrolled in managed care plans (Rowland, 1995). By enrolling Medicaid recipients in managed care plans the states are improving access to care for children while reducing costs.

Capitation has emerged as a method of reimbursement to reduce health care expenditures. The plans are paid a fixed amount per enrollee for medical service regardless of frequency of service (Grimaldi, 1996). Fowler and Anderson (1996) found underpayment for children with chronic illnesses. Further exploration of capitation methods and outcomes are necessary before mass enrollment of children with special needs in managed care plans are mandated by the states.

Pediatric Nurses' Roles

The role for pediatric nurses to promote a continuum of care that provides positive outcomes for children and families are endless in a managed care system. Today's pediatric and child health care delivery is undergoing rapid changes in the managed care revolution. It calls upon pediatric nurses to reexamine their philosophies and approaches in caring for children. Pediatric nurses must contribute to further development of their practice in face of multiple changes in care delivery that impose new challenges and

References

Coeur, M. (Ed.). (1996). Case management practice guidelines. Baltimore: C.V. Mosby Company.

Franklin, J., Solovitz, B., Mason, M., Clemons, J., & Miller, G. (1987). An evaluation of case management. American Journal of Public Health, 77, 674-678.

Fowler, E., & Anderson, G. (1996). Capitation adjustment for pediatric populations. Pediatrics, 98(1),10-17.

Grimaldi, R (1996). A glossary of managed care terms. Nursing Management, Special Supplement 4, 7, 8, 5-7.

Kemper, R (1988). The evaluation of the national long term care demonstration: Overview of the findings. Health Services Research, 23,161-174.

Korenbrot, C., Showstack, J., Loomis, A., & Brindis, C. (1989). Birth weight outcomes in a teenage case pregnancy case management project. Journal of Adolescent Health Care, 10, 97- 104.

Rice, D. (1990). The medical care system: Past trends and future projections. In R R. Lee & C. L. Estes (Eds.), The nation's health (pp. 254-260). Boston: Jones and Bartlett.

Rowland, D. (1995). Medicaid at 30: New challenges for the nation's health safety net. Journal of the American Medical Association, 274, 271-273.

Zander, K. (1994). Nurses and case management: To control or to collaborate. In J. McCloskey & H.K. Grace (Eds.), Current issues in nursing (4th ea.) (pp. 254-260). St Louis: Mosby Year Book.

This issue of Pediatric Nursing introduces a new column "Continuum of Pediatric Care." This column provides a forum for examining health care in a managed care environment and assists nurses in both understanding managed care and learning care coordination skills to best advocate for children and families. We invite readers to submit suggestions of topics, queries, and/or manuscripts for consideration for this column. Correspondence may be addressed to: Christine Golazeski Leyden, MSN, RN, A-CCC, Section Editor, Pediatric Nursing; Anthony J. Jannetti, Inc; East Holly Avenue/Box 56; Pitman, NJ, 00071 0056.

Christine Golazeski Leyden, MSN, RN, A-CCC, is a Continuity of Care Clinical Nurse Specialist and serves as the Director of Patient Care Services at the Hospital for Sick Children in Washington, DC.
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Author:Leyden, Christine Golazeski
Publication:Pediatric Nursing
Date:Mar 1, 1997
Words:1193
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