Managed Care and Minority Healthcare Access in Georgia: an in-depth look at the causes of inaccessibility and assessing transformational needs to provide greater access
Proposal for Chapters 1-3 – Partial Fulfillment of Dissertation
January 6th, 2009
Cynthia B. Brown-Davis
1030 Ashton Oak Circle
Stone Mountain, GA 30083
Mentor: Dr. Frank Kavanaugh
TABLE OF CONTENTS
CHAPTER 1: Introduction and Statement of the Problem.. 3
Statement of the Problem.. 5
CHAPTER 2: Literature Review 6
Theoretical Framework. 6
Critical Literature. 7
Evaluation of Viable Research Designs. 9
CHAPER 3: Methodology. 12
Design Model 12
Sampling Design. 13
Data Collection Procedures. 15
Field/Pilot Testing. 16
Data Analysis Procedures. 16
Design Limitations. 17
Expected Findings. 18
Ethical Issues. 18
Critical Literature. 19
CHAPTER 1: Introduction and Statement of the Problem
Managed care is a term that has evolved as market forces and market reasoning have been incorporated into America’s health care system. Historically, in America, health care was primarily provided by autonomous physicians and patients had to choose their doctor on their own and with few institutional directives. Adapted from government planning efforts and policies, managed care was believed to help patients to make better, more effective choices while saving the nation money as inefficiency was to be reduced.(Dranove, 2000, 3)
However, even though supporters of managed care such as David Dranove assert that: “managed care is working. By one credible source, managed care is saving patients over $300 billion annually. At the same time, there is no systematic evidence that managed care has harmed quality,” and “managed care has clearly won the market test, with the vast majority of privately insured patients enrolled in some type of managed care plan. But managed care has utterly failed to win the trust of American patients and is a favorite target of politicians on both sides of the political spectrum.”(Dranove, 2000, 3) Reasons however, for the widespread dissatisfaction are very real and very legitimate as many people are exposed to too many unnecessary risks and illegitimate discriminations so much so that they receive negligible benefit from their managed care plans.
In a recent study which examined whether discrimination was a factor in receiving benefit from managed care plans, Hass et. al, “suggest that managed care coverage may facilitate the use of preventive health care for Hispanic persons and white persons, but not for black persons or Asian/Pacific Islanders.”(Hass et. al, 2002, 746) As managed care programs focus on outcome and not so much on implementation, a system of rations is imposed to privilege efficiency over comprehensive care. Even though doctors may wish for patients to undergo more tests, for managed care programs, ‘less is more’ so the least amount of testing is usually by their evaluation, the best and most optimal. What only aggravates the problem is that health care costs are rising and have been rapidly escalating since the early 1970s and have become a high-priority national problem. A problem that was extremely difficult to politically address so that an official consensus was never reached in Washington.
However, “The Nixon Administration in the early 1970s was searching for some way of containing costs and rationalizing care and focused on the growing evidence over the decades of the cost effectiveness of prepaid group practice. Repackaged as “health maintenance organizations” by advisor Paul Elwood, and enlarged as a concept encouraging prepaid forms other than group practice, such as independent practice associations, the Federal government began encouraging and subsidizing the growth of HMOs.(Mechanic, 2004, 79) While HMOs had been in place for around 70 years in the united states, federal legislation gave HMOs the resources they needed to expand rapidly by marketing to consumers, some of whom were already covered with Medicaid or Medicare while finding that providers of health care were at that time very eager to sign on because there was an oversupply of hospital beds in the 1980s and 1990s.(Birenbaum, 1997, 17) Increasingly, greed took hold on both sides with doctors sacrificing quality for quantity and patients making less price-conscious choices especially when new technologies hit the scene and tremendously influenced cost mechanisms in health care systems(Birenbaum, 1997, 24)
Yet managed care has primarily been most successful in states that embraced it early and had fewer rural areas, greater economic integration, greater capital resources. In Georgia, some rural areas have not been hit by managed care while “it certainly has reached others and not always to the benefit of the citizens.(Newell, n.d.;22)
Georgia’s legislators, according to a report by Milbank Memorial Fund (1999) are not ready or prepared for managed care. The report states:
Georgia has elected to use an alternative mechanism to deal with the portability requirements of the federal Health Insurance Portability and Accountability Act of 1996 (HIPAA) to address coverage for persons coming from uninsured plans and exhausting COBRA coverage. Georgia's system is an assignment mechanism that requires insurers in the individual market to accept a pro-rata portion of eligible assignees, based on an insurer's market share (Milbank Memorial Fund, 1999).
Statement of the Problem
Managed care is imperative to the health care sector. However, there are many issues surrounding healthcare and access to healthcare. Although it is very difficult to identify, analyze, or be distinct to any one area. This research will concentrate on managed care and minority health care access in Dekalb County, Georgia; and the role ethics plays in health care access. Managed care will be viewed from a practical standpoint. The research will cover some of the issues surrounding managed care reimbursement system(s), as well as strategically managing and evaluating results and clinical outcomes. Some ethical values will also be assessed and recommendation(s) given based on research.
This paper targets the elderly population (Dekalb County, Georgia) age 60 or older, and their health care accessibility or resources. More and more long-term care facilities are becoming refuge, solitude, or incarceration rather than a home or place for recuperating and/or caring for geriatrics to improve their quality of life. This is so for many reasons, most of which are uncontrollable (financial, terminal illnesses, or family members busy work schedules) circumstance that families face. The essence of this research is to target, evaluate, compare, and contrast the past, present, and future of ethics in health care reimbursement and access especially for this population (Georgia Department of Human Resources, n.d.)
CHAPTER 2: Literature Review
The purpose of this study is to evaluate the effects that managed care has on the issue of uninsured and underinsured in the State of Georgia. The research is concentrated on minorities and the elderly groups, as these groups seem to have some concerns about healthcare access. This research will review related literature(s) in an effort to assess past and current findings on related topic(s). Chapter 2 will disclose the researcher’s preferred plan of action including but not limited to theoretical framework, research design, gap in the system (if any), and critical literature. Upon completing this chapter, readers will be able to validate the research reliability and get an insight into what other researcher(s) have found in similar research. The goal of Chapter 2 is for readers to understand the construct of this mixed methodology research.
As managed care is established in organizational terms, the methodological process approach may be especially useful as it incorporates the type of theoretical apparatus that is needed for evaluating behavior and consequences. When the process approach is applied, processes under study can be analyzed and investigations can be more specified.(Mackenzie,2000,110) According to ….: there are four basic ideas behind any group or organizational process. First, all processes involves a time-dependent sequence of these events. Third, any group or organizational process involves five distinct components:
1. The entities (usually people) involved in performing the process,
2. The elements or considerations used to describe the steps or stages in a process,
3. The relationship between every pair of these elements,
4. The links to other processes,
5. The resources and their characteristics-in-use-involved with the elements or
Fourth, the outcome of a process is determined by the process itself.
The organization of Components 2, 3, and 4 is called a process framework. Process frameworks are the bases for models of processes. Pulling these ideas together, a process is defined as a time-dependent sequence of events governed by a process framework.(Mackenzie,2000,113) Although the process approach when applied to managed care has been criticized for not being sensitive enough to the subjective evaluations of patients, additionally methodologies can be supplemented to bring more insight to this research project and provide a better account.
According to Ginter, Swayne, and Duncan (2002) the strength and weakness of any health care organization is dependent on the organization's availability resources, competencies, and ability to execute them to service areas within the organization. These factors (based on external rules) should be strategically applied to pre-service, point-of-service, and post-service areas. Also, these factors are essential to health care organizational analysis as it helps the strategic manager(s) to understand the competitiveness both externally and internally. The ability to effectively compete and find new opportunities is the ability to evaluate the general environment as well as the service areas (Ginter, Swayne & Duncan, 2002).
A report mentioned that the Balance Budget Act (BBA) cut Medicare nationwide by $161 billion between 1998 and 2005; of this amount, $3.4 billion impacted Georgia, which is approximately 1.3 percent. The report also states that Medicare outpatient services in Georgia in the year 2001 saw a loss of $47 million net (Georgia Hospital Association, n.d.).
With the above statistics taken into consideration, there is an anticipation that there may be a decline in the Medicare system in the State of Georgia, due to the lack of sufficient supply to meet the necessary demands, and the $30 million state funding diminution for the fiscal year 2004 (FY04). According to the Georgia Hospital Association (n.d.) the affected areas are: (a) Payments vs. Inflation - payments are much lower than inflation rate, (b) Medicare Liabilities - the liabilities for medical care is vastly increasing, (c) Providers Participation - health care providers are not showing enough participation interest in community affairs, (d) Employers Cost-shifting - the employers are showing workforce deficiency through cost shifting to employees, which puts a limitation on the care given due to inability to pay for services, (e) Uninsured/Under-insured - the number of uninsured and under-insured are increasing, (f) Access - the health care system has too many red tapes, which denies some access, (g) Disaster Preparedness - the need to more advanced disaster preparedness need to be reviewed, and (h) Hospital Capacity - hospital capacity is exhausted due to the disproportionate strain on the emergency department (Georgia Hospital Association, n.d.).
While managed care seems to be on the tip of every health care professional's lips; in Georgia managed care has taken slow progress (Holahan, Rangarajan, & Schirmer, 1999). However, there have been recent attempts to change this view. Holahan, Rangarajan, and Schirmer (1999) points out that managed care is still very much debated in Georgia; especially issues surrounding managed care capitation. In states such as California, Arizona Connecticut, and New York, where Medicaid managed care is still offering low reimbursements; providers are being forced to withdraw services in these states (Holahan, Rangarajan, & Schirmer, 1999). This information is very vital as the research attempts to disclose possible reasoning behind the choice of managed care versus “universal healthcare.”
Evaluation of Viable Research Designs
There are different types of case studies, two of which will be applied to this research: 1. Exploratory – this helps to identify questions, select measurement constructs, and exploits different measures. An exploratory case study also serves to protect and assist with venturing into larger studies. 2. Cumulative – focuses on fairness, culling information across similar past studies, or a potential outlook, while structuring a sequence of research for different times in the future.
These two (2) types of case study would apply and will help readers to understand the minority health care access in Dekalb County, Georgia, and determine whether Georgia’s managed care system, is contributing to the high minority mortality rates in the State. The research will be divided into five case studies, namely:
Study 1 – Cost containment; this portion of the research will assess different methods used since the existence of managed care - this portion of the research will investigate the transformation of managed care from when it started to today’s healthcare setting
Study 2 – For- profit versus not-for-profit healthcare reimbursement system - this assessment will provide readers with a sound understanding of why it is necessary to have more non-profit managed care system
Study 3 – Medicare vs. Medicaid - this portion of the research will outline a comparison between Medicaid and Medicare coverage.
Study 4 – Managed Care funding more public sectors - this study will provide readers with the need for the involvement of more public sectors.
Study 5 – Uninsured vs. Under-insured - finding the gap in minority healthcare access.
The critical research elements and the review of related literatures are included. Chapter 2 dealt with the information gathering and assessment of data as they relate to minority health care and managed care in Georgia. The issue of health care service and delivery starts with the patients’ abilities to pay for services rendered for diagnosis to prognosis, which is for the most part a very difficult tasks as seemingly the people/groups, that need the most health care are usually the ones who are financially challenged. This Chapter uncovered and examined other researchers’ views on similar topics. However, the efforts of the researcher is geared towards finding the relevance of managed care and how it can be applied to allow or deny access to the elderly minority population in Dekalb County, Georgia and proposing a more detailed look at the current system. This research is in an effort to promote further studies on this topic to implement change if needed.
Chapter 2 highlights the fact that this is a mixed method and revolving study. There are no emphasis placed of hard statistical data, but more so the relevance of the data. The researcher found a need to scan Georgia’s health care system, and compare and contrast with neighboring States; while providing a thorough insight in the need for a “universal” health care system.
CHAPER 3: Methodology
This chapter assists with understanding the methods of choice for this mixed methodology research. After completing this chapter, the reasoning behind the methods chosen for this study will be clearly understood. The research will be broken down into five (5) case studies and then conceptualize, in an effort to reveal if there is a gap in Dekalb County’s elderly minority health care access and reimbursement systems.
Despite many critiques that science and scientific philosophies are entrenched in a need for control and an execution of power. A post-positivist researcher does not take knowledge to be rigid or allowing for certain predictions in very many instances. Instead, a post-positivist finds justification for scientific methods because they allow for a consensus on what should be focused on and what should be objects for further research. Within my future assessment of minority health care access and reimbursement systems in the State of Georgia, will be arguments and analysis that can make it easier to later research to occur. As the post-positivist approach is most fruitful for creating a cumulative sense of enlarging our understanding and making more useful predictions, it is very fruitful and is consequently highly regarded by many in the scientific community.
The research design will be a five (5) part exploratory and descriptive (mixed) case study. However, reader should understand that this construct is in an effort to provide a thorough investigative perspective on the managed care/reimbursement system in the State of Georgia. Many researchers in the health care and human services field have opted to use case study in their qualitative research. Researchers such as Muennig and Woolf (2007) in a similar research study for health and economic benefits of reducing the number of students per classroom in US primary schools used case study to reveal the necessary data. This was in an effort for the research to promote further research. However, the researcher understands that a case study can and in many cases have used mixed methods (qualitative – hard data and quantitative- statistical data); this researcher will utilize the qualitative aspect of case study. The following studies will be explored.
Study 1 – Cost Containment; this portion of the research will assess different methods used since the existence of managed care. This portion of the research will investigate the transformation of managed care from when it started to today’s healthcare setting
Study 2 – For- Profit versus Not-For-Profit Healthcare Reimbursement System. This assessment will provide readers with a sound understanding of why it is necessary to have more non-profit managed care system
Study 3 – Medicare versus Medicaid coverage. This portion of the research will outline a comparison between Medicaid and Medicare coverage.
Study 4 – Managed Care funding more Public Sectors. This study will provide readers with the need for the involvement of more public sectors.
Study 5 – Uninsured vs. Under-insured - finding the gap in minority healthcare access.
The sample chosen for this research is non-quota sampling. Non-quota sampling accommodates the use of a small percentage (approximately 1%) of sample for the research as opposed to quota sampling (10% or above). The reason for this choice of sampling is that there is vast number of uninsured citizens in the State of Georgia; in addition, the research can become very expensive to travel to States that have fully adopted managed care. Finally, a non-quota sampling will provide a better sampling frame generally, without being bias.
The reimbursement system in Georgia will be thoroughly assessed and compared to that of other States. Upon reviewing the results, a table will be provided; this table will contain data for Georgia and several other States reimbursement system. Consequently, managed care and Georgia’s healthcare reimbursement system will be analyzed. The sample size will be based on demographics of the uninsured versus the insured minorities within the state. The data will be as follows:
1. Private coverage (individuals & percentage)
2. Public coverage (individuals & percentage)
Using the above statistics will allow a probabilistic (random selection) approach to the research sampling. In contrast, some non- probabilistic data will also be used to construct the calculations affecting the population in general.
Will a more expansive adaptation of a managed care program in the State of Georgia provide greater accessibility to healthcare for minorities? a) What is preventing managed care acceptance in states that it is not widely accepted?
b) Why does managed care work in some states and not in others?
c) Is managed care providing adequate coverage?
d) How can managed care be more conducive to the older adults?
e) Where is the vast majority of the managed care coverage dispersed?
f) How can the managed care reimbursement system be improved?
g) What areas of healthcare are not benefiting from managed care’s existence?
h) What are the political impact on managed care and healthcare delivery?
i) Is the “patient first” era out-played by modern managed care?
2. What are the obstacles affecting a sound managed care implementation in the State of Georgia?
3. How can healthcare coverage reach low-income interstate communities?
Data Collection Procedures
The research will be in the form of a questionnaire, geared towards minority groups, elderly (60+), and clinical facilities in Dekalb County, Georgia. The following steps will be used to gather the data for the research:
Establish a relationship— An established relationship will not be intimate but rather it will be directed towards enhancing perceptions of a necessary scientific neutrality so that participants will feel that their information will not be distorted or used against them.
Professionalism is crucial here, and all attempts must be made to take this very seriously and establish trust so that participants will be as honest as possible in their responses.
Protect privacy – Rigorous steps will be taken in order to protect privacy, responses will be coded and absolute confidentiality will be maintained. Ensure transparency– data should be extracted from valid and reliable sources. Sources should be accessible by individuals wishing to obtain proof of sources. Compare data (several sources) – If data is compared, consistency or inconsistency will be shared. Encourage recommendations – during or after interviews ask for feedback or recommendations. Use deadlines – each portion of the research should have an expected end date, adjustments will be made when necessary. Capitalize on resources – use resources that are free or less costly first; try to utilize as much as possible before spending. Field/Pilot Testing
The research will use qualitative questionnaire to investigate questions listed under the “Measures” section of the methodology outline. The questionnaire used is a public heath assessment questionnaire, adopted from Utah Health Status Survey Questionnaire Office of Public Health Assessment 2007-2008 and approved for use on August 14th, 2008 by Ms. Kathryn Marti (801) 538-6434.
Data Analysis Procedures
Understand the data – due to the fact that qualitative research does not have a hypothesis, the data will be informational. Therefore, the data extracted should be thoroughly evaluated. Use statistics (when and where necessary) – this will ensure that readers understand statistical information and associated dates (proof of relevance). Provide a platform for critical thinking – readers will understand the nature and reasoning behind the research relevance. Encourage recommendations – readers feedback are welcomed
The research is addressing the issue of capitation without violating the department of public health and human services (DHS) standards. Readers will have a brief understanding of the managed care system taking care not to violate DHS or HIPAA standards for patient privacy. Applying the information of the study in a way that will be not be polemic, but will be radical to the need for the health care system in Georgia. Structuring the survey questions in such a way that it highlights patients’ rights. The knowledge base gap: finding reliable sources and consistency in statistical evidence. Validity
The resources used will be validated and assessed before the data is extracted. Therefore, the research will use valid sources for information; see below:
The internal validity will be assessed through Capella’s chosen IRB.
The results will be tested for validity and reliability by comparison with the State’s Department of Health (DoH) website statistical data. The results will also be verified with a with national DoH information site (as reported for the State of Georgia). The questionnaire used will be adopted from the 2007-2008 Utah Health Status Survey Questionnaire; the use of this questionnaire has been approved by Ms. Name on Date.
The State of Georgia has not yet fully adopted managed care. Therefore, residents have to use out-of-State managed care reimbursement systems. This research is in an attempted to look at how managed care work in other states and provide a proposal to readers indicating how managed care services can successfully be utilized in Georgia to give minority groups greater access. The research will provide a SWOT analysis on the Georgia’s current reimbursement system(s); and provide statistical data of Georgia in comparison to other states. The issue of uninsured and underinsured will also be addressed in this research. Readers will have a practical insight of the need to have healthcare coverage for those who need it the most.
Successful policy implementation in health care requires a thorough application of health care law, ethics, diversity, and sound economical support to facilitate change and at the same time focus on quality. Furrow (2004) describes health care laws as a module that concentrates on all areas of health care, such as; research, pharmaceutical, health care facilities, and patients. In a complex health care environment, there is a vast amount of emphasis placed on the intensity of issues such as medical malpractice, managed care, epidemiology, and new drugs. Furrow (2004) also states that the rules and regulation that are implemented by the government are in a state of haphazardness. Not to mention that there is no platform implemented for addressing the need for a national healthcare reimbursement system, which will accommodate minorities (Furrow, 2004).
The purpose of Chapter 3 is to help assess and examine the data collection procedures, methodology, strategies, reliability, and validity of the data that will be used to evaluate the resources and methods used in this study. Managed care has been around for more than a decade; however, some States like Georgia have failed to adapt fully to managed care. The purpose of this study is to enable readers to see the lack of proper health care coverage and the effects it has on the elderly and minority groups. Considering the constant effort for cost-containment in healthcare, the very first issue is the supply versus the demand for health care. According to Feldstein (2003) theory “imbalances between demands for care and supply of services will occur” (Feldstein; 2003, p.200) However, as my study seeks to stress, the situation is far from a quick fix but rather part of a process which has many nodes of interaction.
In order to do justice to this issue, a lot of stress will be placed on executing this as rigorously as possible while maintain a highly monitored system of ethics so that participants are not at all manipulated or their rights infringed.
Managed care has, since its existence attempted to resolve a great deal of healthcare disparities: from cutting cost to delivering better healthcare access for the working class families. However, the issue of minority access (uninsured and underinsured) and universal healthcare coverage seem to be unresolved not just statewide, but also nationwide; this research attempt to address these issues in the State of Georgia. It should be noted that this research is an effort to open the doors to many more research on this or similar topics not just in Georgia but in other States also.
Managed care seems to be the buzzword on every health care professional's lips; although in Georgia managed care is seemingly non-existent. However, there have been recent attempts to change this view. Holahan, Rangarajan, and Schirmer (1999) points out that managed care is still very much debate in Georgia, especially issues surrounding managed care capitation. In states such as California, Arizona Connecticut, and New York, Medicaid managed care is still offering low reimbursements, which is forcing providers to withdraw services in these states (Holahan, Rangarajan, & Schirmer, 1999). This information is very vital as the research attempts to disclose possible reasoning in the choice of managed care versus “universal healthcare.”
Various problematical issues arise especially when healthcare is defined and redefined by rapidly changing medical technology, expectations of longevity, and encroaching budgetary concerns. What kind of health care can we afford should be the question and taking steps towards providing potentially usable answers will require a lot of careful observation, inquiry, and last of all, a disciplined methodology and solid explanatory principles.
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