Controlling costs and changing patient care? : the role of utilization management / Committee on Utilization Management by Third Parties, Division of Health Care Services, Institute of Medicine ; Bradford H. Gray and Marilyn J. Field, editors.

Format:

Book

Author/Creator:

Institute of Medicine (U.S.). Committee on Utilization Management by Third Parties.

Contributor:

Gray, Bradford H., 1942-

Field, Marilyn J. (Marilyn Jane)

Language:

English

Subjects (All):

Cost control.

Health services administration--United States.

Health services administration.

Physical Description:

1 online resource (viii, 312 pages) : illustrations

Edition:

1st ed.

Place of Publication:

Washington, D.C. : National Academy Press, 1989.

Language Note:

English

Summary:

Utilization Management has become a strong trend in health care cost containment. Under UM, some decisions are not strictly made by the doctor and patient alone. This book presents findings about how UM is faring in practice and how it compares with other cost containment approaches, with recommendations for improving UM program administration.

Contents:

Controlling Costs and Changing Patient Care?

Copyright

Contents

Preface

Executive Summary

CURRENT STATUS OF UTILIZATION MANAGEMENT

HOW UTILIZATION MANAGEMENT IS EVOLVING

ISSUES FOR THE FUTURE

RECOMMENDATIONS FOR THE NEAR TERM

Responsibilities of Employers and Purchasers

Responsibilities of Utilization Management Organizations

Responsibilities of Practitioners and Institutions

Responsibilities of Patients

LONGER-TERM RECOMMENDATIONS AND QUESTIONS

Research On Effectiveness

Practice Guidelines and Review Criteria

Oversight of Utilization Management

1 Utilization Management: Introduction and Definitions

WHAT IS UTILIZATION MANAGEMENT?

Prior Review

High-Cost Case Management

Retrospective Utilization Review

Other Cost-Containment Methods

TWO NOTES OF CAUTION

Obstacles To Evaluation

Intrinsic Conceptual and Methodological Problems

Common Behavioral Biases Against Evaluation

Competition and Evaluation

Forces Behind Rising Health Care Costs

REFERENCES

2 Origins of Utilization Management

THE GROWTH OF THIRD-PARTY FINANCING OF HEALTH CARE

EARLY COST-MANAGEMENT EFFORTS BY THIRD PARTIES

Management of the Risk Pool

Design of the Benefit Plan

Controls On Payments To Providers

Constraints On Supply

Utilization Review

GOVERNMENT AND EMPLOYER INVOLVEMENT

Federal Government Initiatives

Private Purchasers Become an Force

OTHER FACTORS GIVING RISE TO UTILIZATION MANAGEMENT

Inappropriate Utilization as an Cost-Containment Target

Variations in Utilization

Inappropriate Utilization

Linking Cost and Quality

Improving the Tools and Structures for Utilization Management

Information Resources

Assessment and Education Strategies

New Organizations

CONCLUSION

REFERENCES.

3 The Utilization Management Industry: Structure and Process

INDUSTRY OVERVIEW

THE REALITIES OF PRIOR REVIEW: HOW IS IT ACTUALLY DONE?

How Prior Review Is Integrated with Other Administrative Functions

How Basic Logistical Matters Are Handled

Initiating Review

Handling Telephone Calls

Computerization

How Nurse Reviewers Work

What Role Do Physician Advisers Play?

What Style Is Used with Attending Physicians?

What Criteria Are Used to Assess Care?

Lists of Procedures

Exceptions Criteria

Hospitalization Criteria

Length-Of-Stay Norms

Necessity of a Procedure

How Criteria Are Adopted and Modified

How Organizations Use Criteria

Appeals Processes

Reporting and Feedback Mechanisms

SECOND-OPINION REQUIREMENTS

LEGAL ISSUES

4 Impact of Prior Review Programs

DIRECTION OF AVAILABLE EVIDENCE: IMPACT ON UTILIZATION AND COST

Before-and-After Studies

Comparative Studies

Multivariate Studies

Impact of Second-Opinion Programs

WEAKNESSES IN THE EVIDENCE ON EFFECTS OF PRIOR REVIEW

EFFECTS OF PRIOR REVIEW ON SPECIFIC PARTIES

Effects on Enrollees and Patients

Quality of Care

Navigating Health Care and Health Benefits

Patient Costs, Comfort, and Convenience

Effects on Health Care Practitioners and Institutions

Physician-Patient Relationship

Physician-Hospital Relations

Provider-Purchaser Relations

Effects of Prior Review on Purchasers

APPENDIX SOME METHODOLOGICAL ISSUES IN ASSESSING THE EFFECTS OF UTILIZATION MANAGEMENT PROGRAMS

Claims Data

Group Data

Program Data

Savings Calculations

Other Interventions

Medical Care Prices

Noneconomic effects

5 High-Cost Case Management

FOCUS OF HIGH-COST CASE MANAGEMENT

ROLE OF THE PURCHASER

HOW HIGH-COST CASE MANAGEMENT WORKS.

Operational Variations

How Cases Are Identified and Screened

Who Serves as Case Manager?

How Case Managers Relate to Patients and Providers

How Much Case Management Costs

IMPACT OF HIGH-COST CASE MANAGEMENT

EFFECTS OF HIGH-COST CASE MANAGEMENT ON SPECIFIC PARTIES

Effects on Enrollees

Effects on Health Care Providers

Effects on Purchasers

QUESTIONS ABOUT AVAILABLE EVIDENCE

LEARNING CURVE IN HIGH-COST CASE MANAGEMENT

POTENTIAL LEGAL ISSUES

6 Conclusions and Recommendations

Scope of Review

Operational Efficiency

Rationing

Responsibilities of Health Care Practitioners and Institutions

RECOMMENDATIONS AND QUESTIONS FOR THE LONGER TERM

Research on Effectiveness

Acknowledgments

Appendixes

Appendix A Legal Implications of Utilization Review

Introduction

The Types of Utilization Review

The Sarchett Decision

The Wickline Decision

The Elusive Concept of Medical Necessity

Liability of the Review Organization

Negligence

Existence of an Duty of Care

The Standard of Care

Causation

Breach of Contract

Insurance Bad Faith

Infliction of Emotional Distress

Warranty Theories

Products Liability

Defamation and Interference with Contractual Advantage

Antitrust

Liability of Consultants and Employees

State Regulation

Erisa Preemption

Liability of the Employer or Payer

Direct Liability

Vicarious Liability

Indemnity.

Liability of the Treating Physician

Legal Issues For the Patient

The Need For Expedited Review

Payment For Unnecessary Medical Services

Conclusion

References

Appendix B Utilization Management and Quality Assurance in Health Maintenance Organizations: an Operational Assessment

Methodology

Hmo Organizational Structure

Market, Structural, and Operational Factors Affecting Hmo Performance

The Health Care Marketplace

Hmo Structure

Hmo Operations

Approaches to Utilization Management and Quality Assurance

Underwriting Benefits

Delivery of Health Services

Quality Assurance

Operational Problems Impairing Utilization Management and Quality Assurance Programs

Utilization Management Programs

Design and Use of Physician Incentives

Background

Current Surveys Concerning Physician Incentives

Administering Physician Incentives

Policy and Research Issues

Case Studies Introduction

Case Study 1: Hospital-Sponsored Ipa

Control Type

Financial Incentives

Design of Mis System

Utilization Management

Medical Director and Utilization Management Support Staff

Case Study 2: Group-Model Hmo

Case Study 3: Carrier-Sponsored Hmo

Case Study 4: Carrier-Sponsored Hmo

Utilization Management and Support Staff

Case Study 5: Physician-Sponsored Ipa

Control Type.

Financial Incentives

Ipa Management

Notes and References

Appendix C Utilization Management in Peer Review Organizations

Appendix D Summary of Public Hearings

Appendix E Summaries of Committee Site Visits To Utilization Management Organizations

Organization 1

Organization 2

Organization 3

Organization 4

Organization 5

Organization 6

Organization 7

Organization 8

Organization 9

Organization 10

Organization 11

Organization 12

Appendix F Analysis of Agreements Between Utilization Management Organizations and Their Clients

Contractual Descriptions of Prior Review Services

Sources of Clinical Criteria and Standards

Distinction Between the Review Determination and Purchaser's Decision To Pay For Services

Indemnification and Liability Insurance Coverage

Staffing and Performance Criteria

Proprietary Information and Competition

Appendix G Glossary and Acronyms

Glossary

Acronyms

Appendix H Biographies of Committee Members

Index.

Notes:

Bibliographic Level Mode of Issuance: Monograph

Includes bibliographical references.

ISBN:

9786610214457

9781280214455

1280214457

9780309543095

0309543096

9780585144573

0585144575

OCLC:

666935505