Can the NHS learn from US managed care organisations? A new King's Fund study identifies factors associated with efficient management of chronic disease in the United States.(Education and debate)

Summary points

Competitive pressures between managed care organisations provide an incentive for innovation in management of chronic diseases

Doctors in these organisations have a strong management role

Goals are agreed between clinicians and managers, and financial incentives exist to improve care

All managed care organisations identify high risk patients and target intensive nurse led outreach care to minimise hospital admissions

Multifaceted chronic disease management programmes were used, in which self care and patient education were central features

Managed care organisations in the United States have some parallels with primary care trusts in the NHS. A key aim of both is to improve health so that avoidable use of health care is reduced. Managed care organisations have strong inbuilt incentives to manage the care of enrolled patients proactively (box 1). Two studies recently reported that hospital admissions and use of day beds for the population of one managed care organisation, Kaiser Permanente North California, were less than that for a comparable population in the NHS. (2 3) The findings raised hot debate, and the study by Feachem et al was criticised mainly because of the methods of comparing the US and NHS populations served and costs. (4) On the assumption that the reduction is real, we examine what factors might contribute and whether the NHS could adopt them.

 
Box 1: Functions of a typical managed care organization (1) 
 
* Monitor and coordinate care for an enrolled population for a fixed 
annual fee 
 
* Monitor and coordinate care throughout the entire range of services 
(primary to tertiary care) 
 
* Emphasise prevention and health education 
 
* Encourage the provision of rare in the most appropriate setting by 
the most appropriate provider 
 
* Promote the cost effective use of services through various means 

Background

The Department of Health is already funding two pilot projects modelled on Kaiser Permanente (5) and another major managed care organisation, United Health Care, in 18 primary care trusts in England. (6) Nevertheless, there seems to be no consensus about why hospital admission mad day bed rates might be lower in managed care organisations or the useful lessons for the NHS. (2-4) We studied how five relatively highly performing managed care organisations organise care for people with chronic conditions, such as asthma, diabetes, chronic obstructive pulmonary disease, and heart failure. We focused on chronic conditions because they are among the costliest to treat in the NHS and the United States, (7) evidence exists that effective ambulatory care can reduce the risk of inpatient care, and the large variations in rates of hospital admission by primary care trusts suggests that care of patients in the NHS could be better. (8) The full report is available from …