Assignment: Congestive Heart Failure
In response to a growing anti–managed care sentiment and in the face of pos- sible legislation designed to hold managed care companies legally accountable for directly managing care through preadmission authorizations and utilization review, managed care companies such as UnitedHealthcare pursued new methods to finance and deliver improved care while holding down costs. One method is evidence-based case management, in which managed care companies partner with providers to determine the best, and thereby the most efficient, way to manage a case based on current evidence. For instance, in the late 1990s, Anthem Blue Cross and Blue Shield collaborated with physicians and hospitals in Indiana, Ohio, and Kentucky and established a goal of administering ACE (angiotensin-converting enzyme) inhibitors to 60 percent of health plan members diagnosed with congestive heart failure. In Indiana hospitals from 1998 to 2001, the use of ACE inhibitors increased from 52 percent to 60 percent. Hospitals and physicians who met the targets were reimbursed more than hospitals and physicians who did not meet the targets (Nowicki 2003).
Another method designed to give health plan members choices in coverage that also seems to save money is the move toward high-deductible health plans. As the cost of healthcare continues to rise, employers are passing more of the cost to their employees or not providing healthcare at all. This economic phenomenon occurs at the same time as a demographic phenomenon—a large portion of the population, the baby boomers, are in their 60s and need more healthcare. High-deductible health plans allow consumers to select the coverage they need or want and pay the corresponding premiums (Millenson 2003).
Humana, one of the nation’s largest health plans, may have been the first to try a consumer-driven plan with its own employees. Humana’s chief executive officer, Michael McCallister, said, “I’m a big believer that the most powerful player in understanding and
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