Economic challenges in managed care settings are also prevalent in educational outreach efforts. There is a potential risk of biased enrollment, with capitated plans preferentially seeking low-risk clients who require less care. There is also the risk of disincentives in which capitated plans may limit costly services, for example, to patients with human immunodeficiency virus infection.
These scenarios could present dire problems in managed care. Certain drawbacks, however, might mitigate the restrictions imposed by managed care organizations. These include expansion of insurance coverage as well as provision of educational subsidies to physicians who take the time to educate their patients. These methods, however, cost money and may therefore not be attractive alternatives to some. Another concept is risk adjustment, in which reimbursement is tailored to the degree of difficulty involved in patient care. Current models, however, are still in rudimentary stages. In addition, these risk adjustment models also tend to resemble fee-for-service techniques, which managed care systems are attempting to avoid because of the economic implications resuiting from this reimbursement method. Other possibilities include self-referral to a subspecialist, application of outcomes research to guidelines themselves in an effort to ensure that compliance with guidelines does not displace attention to other clinical problems, and lastly, the controversial approach of forming provider-based managed care organizations.
Jonathan R. Davis, Ph.D., Editor
Managed care systems are in a stage of a rapid transition. Assistance with the delivery of health care and building strength in support of educational efforts is necessary to effectively deal with the myriad issues associated with the coordination of health plan research and educational and outreach efforts.
Widespread, unnecessary use of antibiotic agents is a major contributing factor in the spread of antibiotic resistance. Economic factors largely influence the prescription practices of managed care physicians, and patients do not fully understand when it is appropriate to take antibiotics. Emphasis on controlling costs in managed care can lead to incorrect diagnoses, underreporting of some infectious disease conditions, and inadequate follow-up care. The essential role that physicians can play in accurately reporting diseases is generally not adequately communicated. Managed care organizations are increasingly able to be accountable for the appropriateness and quality of clinical care. Not only do they have the infrastructure to improve infectious disease surveillance through the systematic collection of encounter-level data and the standardization of computerized systems for the monitoring of data on health care, but they are also equipped to educate providers on the importance of their role in accurate disease reporting. Not only does this accuracy improve the quality of clinical care, but it also helps control the spread of diseases by providing the best available treatment.