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Managed Care

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Health & Medical
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Disease management programs tend to be developed and proliferate where an oversupply of
physicians or hospitals exist. Because of increased competition and demand from employer, the
health care system that focus on outcomes and can deliver these quality improvement changes
initiated programs to meet these requirements. Often when the reimbursement structure changes
to capitation or a set free per patient, disease management programs are instituted to promote
education and self-help and shift costly care to the most appropriate, cost-effective site of care.
Predictive modeling, a mathematical approach to patient identification is need of additional
health resources, is a new action to the disease management repertoire. Previously used in
financial services to predict credit risk, in meteorology for weather events, and by colleges for
academic performances, pre-addictive modeling attempts to find consumers who are at risk for
chronic conditions. Using medical and/or pharmacy claims in conjunction with demographics
and self-reported information, the analysis predicts risk or health care costs for the future.
Approaches to predictive modeling vary from identification of at-risk or undiagnosed patients to
detection of patients lacking a clinical guideline recommendation, to those who could benefit
from findings in newly published research. The focus of predicting modeling is the improvement
of clinical outcomes by supporting clinicians and consumers in decision-making.
The next generations of disease management may expand to a “total population management”
approach through customized resources for risk identification and stratification, wellness
programs, disease and case management and end-of life care (Edlin, 2002, p.46). Although
disease management continues to be present as long as there are chromic conditions, health
management will focus on chronically ill populations as well as healthy groups. Health
promotion programs have long been the cornerstone of nursing. No matter the name, program
components or sponsor nurse are vital to the process of improving care for populations. Optimal

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Disease management programs tend to be developed and proliferate where an oversupply of physicians or hospitals exist. Because of increased competition and demand from employer, the health care system that focus on outcomes and can deliver these quality improvement changes initiated programs to meet these requirements. Often when the reimbursement structure changes to capitation or a set free per patient, disease management programs are instituted to promote education and self-help and shift costly care to the most appropriate, cost-effective site of care. Predictive modeling, a mathematical a ...
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