In today's health care environment tremendous efforts are being made by Health Maintenance Organizations (HMOs) to deliver appropriate patient care while controlling utilization of services and costs. One area of concern over the past two years has been the apparent over-utilization of spinal surgeries within a local Senior HMO. This HMO has no specific plan or physician guidelines for the management of low back pain. Utilization of spinal surgeries is measured in incidence of admissions per thousand members of the Senior HMO. Over the past two years the incidence of spinal surgeries per thousand has grown from 2.4 in 1995, 4.1 in 1996 and 7.4 during the first quarter of 1997. This is compared to a suggested rate of 1.5 per thousand for similar HMO populations around the country. The purpose of this study was to determine the effectiveness of the presentation of a treatment algorithm and physician guidelines for the management of low back pain (LBP). In order to determine the effectiveness of the presentation of the algorithm, the incidence of spinal surgeries per thousand for nine quarters prior to the presentation was compared to the incidence per thousand for the three quarters following the presentation. Results of this comparison showed a slight drop, but statistically insignificant (P = .62), in the rate of surgeries compared to the previous year. When compared to the previous two years the rate was actually slightly higher, but statistically insignificant (P = .57) after the presentation. Although the comparisons were determined to be insignificant, trend analysis indicated a gradual rise in the incidence during the initial five quarters, a plateau during the next four quarters, and a slight decrease in the rate of surgeries during the last three quarters which followed the introduction of the treatment algorithm. At this time it would be appropriate to continue the analysis of quarterly data and continue feedback and education to the primary care physicians in an attempt to promote proper utilization of spinal surgeries and overall management of LBP.

The utilization of ambulatory services by the health maintenance organization of Florida (HMO), independent practice association (IPA) model, was compared to a fee-for-service population. Each randomly selected group consisted of 250 patients being cared for by the same providers, at the same clinic, during the calendar year 1986. Demographic and clinical data was gathered from the office charts. Frequencies were evaluated by the Statistical Package for the Social Sciences and t-tests were run to substantiate variance at the 0.05 level of confidence. The HMO group is a younger population (t = 0.017), and the males are responsible for the increased utilization of ambulatory services (t = 0.001). Trends of increased utilization are noted across the age groups and the variables. The rate of hospitalization is insignificantly higher for the HMO population and covers a broader range of age groups. Consequently, this HMO IPA model increases the rate of ambulatory service utilization in a younger population without reducing the rate of hospitalization. Cost effectiveness studies and organizational management evaluations are needed.

This thesis examines several recent transformations in the United States health care system and their effects on the role of physicians. Technology, specialization, ancillary health care workers, for-profit hospitals and managed care corporations have all expanded throughout the health care industry. These changes have resulted in an increase in bureaucratic, capitalist and corporate influences over the system. As a result of the increasing costs of medical practice, the corporatization of health care is occurring in which physicians must not only rely on corporations for access to the capital that they need, but also relinquish some of their power to the corporations. McKinlay and Arches (1985) assert that these changes have led to the proletarianization of the physician. Health maintenance organizations (HMOs) and other forms of managed care companies continue to grow throughout the United States. Therefore, physicians, who have historically dominated the health care system, no longer have the autonomy that they once had. To measure physicians' attitudes toward these changes, The Managed Care in the New River Valley survey was conducted. The findings show that although managed care is not as strong as it is in other parts of the country, physicians still believe that their control of health care is declining. The importance of managed care companies and other third party influences will continue to increase in the future, as they further extend to areas such as the New River Valley. / Master of Science

A presente pesquisa investiga os impactos da regulação econômica nas escolhas de práticas contábeis. Buscando identificar a relação existente, são apresentadas pesquisas em gerenciamento da informação contábil (de resultado e do balanço patrimonial) e as teorias econômicas da regulação. Em seguida, são apresentadas as evidências empíricas de como a regulação econômica incentiva a adoção de determinadas práticas contábeis. Nesse mister, é apresentada a regulação financeira exercida pela Agência Nacional de Saúde Suplementar (ANS) sobre as entidades operadoras de planos de assistência à saúde (OPS), também chamadas de planos de saúde. Essa regulação financeira consiste no acompanhamento, pela ANS, da situação econômico-financeira das OPS. A ANS compara os índices calculados a partir das informações contábeis recebidas, eletronicamente, das OPS, com parâmetros estabelecidos a priori. Se determinada OPS não atender, satisfatoriamente, os parâmetros, fica sujeita ao afastamento de seus administradores de suas funções e até à liquidação de seus ativos. Por fim, as teorias da regulação e do gerenciamento da informação contábil são revisitadas à luz da Nova Economia Institucional, identificando-se, portanto, a Contabilidade como parte integrante de um contrato (regulação) cujos custos são diferentes de zero (custos de transação), de forma que a informação contábil é a cola que mantém a firma unida e a regulação financeira em atividade. / This study analyzes how the economic regulation impacts on accounting policy choices. With a view to identifying the existing relationship between both, the economic theories of regulation and research on earnings and balance sheet management are discussed. Then, empirical evidence is presented of how economic regulation stimulates the choice of certain accounting policies, related to the Brazilian Health Care Agencys (ANS) equivalent to the US Federal governments Office of Health Maintenance Organizations financial regulation of health maintenance organizations (HMO), called OPS in Brazil. OPS have their economic-financial situation monitored by the ANS, which compares the indices calculated on the basis of electronically received financial information with some previously established financial thresholds. If these are not complied with to a reasonable extent, this may lead to the HMOs liquidation. Finally, the regulation and earnings and balance sheet management theories are discussed under the lens of New Institutional Economics, which sees Accounting as part of a contract (regulation), whose costs are positive (transaction costs), and accounting information as the glue that keeps the firm together and keeps the financial regulation working.

A presente pesquisa investiga os impactos da regulação econômica nas escolhas de práticas contábeis. Buscando identificar a relação existente, são apresentadas pesquisas em gerenciamento da informação contábil (de resultado e do balanço patrimonial) e as teorias econômicas da regulação. Em seguida, são apresentadas as evidências empíricas de como a regulação econômica incentiva a adoção de determinadas práticas contábeis. Nesse mister, é apresentada a regulação financeira exercida pela Agência Nacional de Saúde Suplementar (ANS) sobre as entidades operadoras de planos de assistência à saúde (OPS), também chamadas de planos de saúde. Essa regulação financeira consiste no acompanhamento, pela ANS, da situação econômico-financeira das OPS. A ANS compara os índices calculados a partir das informações contábeis recebidas, eletronicamente, das OPS, com parâmetros estabelecidos a priori. Se determinada OPS não atender, satisfatoriamente, os parâmetros, fica sujeita ao afastamento de seus administradores de suas funções e até à liquidação de seus ativos. Por fim, as teorias da regulação e do gerenciamento da informação contábil são revisitadas à luz da Nova Economia Institucional, identificando-se, portanto, a Contabilidade como parte integrante de um contrato (regulação) cujos custos são diferentes de zero (custos de transação), de forma que a informação contábil é a cola que mantém a firma unida e a regulação financeira em atividade. / This study analyzes how the economic regulation impacts on accounting policy choices. With a view to identifying the existing relationship between both, the economic theories of regulation and research on earnings and balance sheet management are discussed. Then, empirical evidence is presented of how economic regulation stimulates the choice of certain accounting policies, related to the Brazilian Health Care Agencys (ANS) equivalent to the US Federal governments Office of Health Maintenance Organizations financial regulation of health maintenance organizations (HMO), called OPS in Brazil. OPS have their economic-financial situation monitored by the ANS, which compares the indices calculated on the basis of electronically received financial information with some previously established financial thresholds. If these are not complied with to a reasonable extent, this may lead to the HMOs liquidation. Finally, the regulation and earnings and balance sheet management theories are discussed under the lens of New Institutional Economics, which sees Accounting as part of a contract (regulation), whose costs are positive (transaction costs), and accounting information as the glue that keeps the firm together and keeps the financial regulation working.

The purpose of this study is to explore differences in quality between Medicare Accountable Care Organizations (ACO) and Health Maintenance Organizations (HMO). Three outcomes measures reported by these plans use different methodologies but possess enough alignment to permit comparison: percent of diabetic patients with last HbA1c > 9.0%, colon cancer screening rate and ER visits per 1,000. These outcomes are the dependent variables (DV). A secondary purpose is to explore differences in quality based on the size of the beneficiary population served, using the same measures. As the Medicare program faces threats to its solvency in coming decades, with 10,000 baby boomers becoming eligible every day, and the ongoing national conversation about healthcare more generally, approaches to Value-Based Purchasing (VBP) are becoming more common. Organizations seeking to identify the types of VBP arrangements in which they should enter have precious little information on the comparative performance of VBP approaches relative to outcomes measures. Different structures create different incentives through the plan design and risk/reward. The convergence or dissipation of the plan incentives at the level of the provider, particularly in primary care, may be a source of variance. This study is retrospective, non-experimental, and uses publicly available data on the performance of Medicare ACO and HMO plans in calendar year 2015, for the identified measures. Using the Donabedian Structure-Process-Outcome framework, this study explores the impact of structure by type of plan and size of population served, relative to the outcomes. Race, average Hierarchical Condition Category (HCC) risk score and duration of operations are control variables. The analysis uses multiple hierarchical regression to better understand the relationship between the independent variables (IV) and DVs, after the impact of the control variables (CV). After controls, the IVs did offer some explanation of variation in outcomes. The ACO plans fared better on HbA1c control, while HMO plans had fewer ER visits per 1,000. No discernable difference existed between the HMO and ACO plans with regard to colon cancer screening rate. Serving larger populations led to better performance on all three measures. In general performance was worse on each measure in both models when the percent of not-White patients or average HCC risk score increased. A longer duration of operations also associated to better performance on the outcome measures.

Thesis (Ph. D.)--RAND Graduate School, 2002. / Includes bibliographical references (p. 96-101).

Thesis (Ph.D.)--RAND Graduate School, 2002. / Includes bibliographical references (p. 96-101).

No description available.

Submitted by Marcia Bacha (marcia.bacha@fgv.br) on 2013-10-22T18:13:27Z No. of bitstreams: 1 Dissertação_Felipe_Ramos_Ferreira.pdf: 330714 bytes, checksum: d8a4161c827849680a2086bf46f85c3b (MD5) / Approved for entry into archive by Marcia Bacha (marcia.bacha@fgv.br) on 2013-10-22T18:13:42Z (GMT) No. of bitstreams: 1 Dissertação_Felipe_Ramos_Ferreira.pdf: 330714 bytes, checksum: d8a4161c827849680a2086bf46f85c3b (MD5) / Approved for entry into archive by Marcia Bacha (marcia.bacha@fgv.br) on 2013-10-22T18:15:10Z (GMT) No. of bitstreams: 1 Dissertação_Felipe_Ramos_Ferreira.pdf: 330714 bytes, checksum: d8a4161c827849680a2086bf46f85c3b (MD5) / Made available in DSpace on 2013-10-22T18:15:18Z (GMT). No. of bitstreams: 1 Dissertação_Felipe_Ramos_Ferreira.pdf: 330714 bytes, checksum: d8a4161c827849680a2086bf46f85c3b (MD5) Previous issue date: 2009 / A presente pesquisa busca investigar se a auditoria externa (independente) minimiza a propensão à manipulação das informações contábeis - MIC (medidas pelas acumulações discricionárias correntes) por parte das operadoras de plano privado de assistência à saúde, no que tange às informações econômico-financeiras divulgadas à Agência Nacional de Saúde Suplementar. Após revisão bibliográfica sobre qualidade da informação contábil, auditoria e mercado de saúde suplementar, promoveu-se uma pesquisa empírica com informações prestadas à ANS pelas OPS relativas ao período de 2004 a 2006. Para verificar se há diferença significativa no nível de acumulações discricionárias correntes, medidas pelo modelo AWCA e Jones Modificado (1995), entre as informações auditadas (quarto trimestre de cada ano) e as informações nãoauditadas (três primeiros trimestres de cada ano) para as mesmas empresas foi aplicado o teste não-paramétrico de Mann-Whitney. Os resultados indicam que não existem diferenças estatísticas significativas na propensão à manipulação entre as informações contábeis auditadas e não-auditadas, pelo menos no que tange às informações de 2004 a 2006 prestadas pelas OPS à ANS. Adicionalmente, também foram testadas as influências do tipo de modalidade, porte da firma e situação apresentada do patrimônio líquido sobre as acumulações discricionárias correntes. Observou-se que essas três variáveis influenciam em maior ou menor grau na manipulação da informação contábil gerada pelas OPS à ANS. Neste contexto, as seguintes características sobre a maior propensão a MIC foram diagnosticadas: Cooperativa Odontológica e a Medicina de Grupo (Modalidade); Pequeno (Porte da Firma); e Passivo a Descoberto ou PL Próximo de Zero (Situação do Patrimônio Líquido). Ao passo que as características relacionadas à menor propensão de MIC foram: Cooperativa Médica e Filantropia (Modalidade); Médio e Grande (Porte da Firma); Patrimônio Líquido Favorável (Situação do Patrimônio Líquido). / This research aims to investigate whether the external (independent) audit minimizes the propensity for manipulation of accounting information (measured by discretionary current accruals) by health maintenance organizations (OPS), in regard to financial information disclosed to the Brazilian Health Care Agency (ANS). Based on a literature review of external audit, manipulation of accounting information and health care industry we developed an empirical research to information provided by OPS to the ANS for the period 2004 to 2006. To test for significant differences in the level of discretionary current accruals, measured by AWCA model and modified Jones (1995), we compared the quality of audited information (fourth quarter of each year) with the quality of non-audited information (the first three quarters of each year) from the same companies. This difference was investigated by the nonparametric Mann-Whitney test. The results indicate that there are no statistically significant differences in the propensity to manipulation of accounting information between audited and non-audited financial reports, at least in relation to information from 2004 to 2006 provided by OPS to the ANS. In addition, there were also tested the influence of type of procedure, size of firm and the situation presented in shareholders' equity on the discretionary current accruals. It was observed that these three variables influence a greater or lesser degree in the manipulation of accounting information generated by the OPS to the ANS. In this context, the following features on the more likely the MIC were diagnosed: Cooperative Dental and Medical Group (Type of Procedure); Small (Size of Firm); and Negative Equity or close to zero (Situation Presented in Shareholders’ Equity). On the other hand, the main features that are less likely to MIC were: Cooperative Medical and Philanthropy (Type of Procedure); Medium and large (Size of Firm); and Equity Favorable (Situation Presented in Shareholders’ equity).