LEADER 10989nam 2200673Ia 450 001 9910828354403321 005 20200520144314.0 010 $a1-280-21445-7 010 $a9786610214457 010 $a0-309-54309-6 010 $a0-585-14457-5 035 $a(CKB)110986584750886 035 $a(OCoLC)666935505 035 $a(CaPaEBR)ebrary10062860 035 $a(SSID)ssj0000130179 035 $a(PQKBManifestationID)11132557 035 $a(PQKBTitleCode)TC0000130179 035 $a(PQKBWorkID)10080639 035 $a(PQKB)10964032 035 $a(MiAaPQ)EBC3376969 035 $a(Au-PeEL)EBL3376969 035 $a(CaPaEBR)ebr10062860 035 $a(CaONFJC)MIL21445 035 $a(OCoLC)940510411 035 $a(EXLCZ)99110986584750886 100 $a19890818d1989 uy 0 101 0 $aeng 135 $aurcn||||||||| 181 $ctxt$2rdacontent 182 $cc$2rdamedia 183 $acr$2rdacarrier 200 10$aControlling costs and changing patient care? $ethe role of utilization management /$fCommittee on Utilization Management by Third Parties, Division of Health Care Services, Institute of Medicine ; Bradford H. Gray and Marilyn J. Field, editors 205 $a1st ed. 210 $aWashington, D.C. $cNational Academy Press$d1989 215 $a1 online resource (viii, 312 pages) $cillustrations 300 $aBibliographic Level Mode of Issuance: Monograph 311 0 $a0-309-04045-0 311 0 $a0-309-04048-5 320 $aIncludes bibliographical references. 327 $aControlling 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. 327 $a3 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 -- CONCLUSION -- REFERENCES -- 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 -- CONCLUSION -- 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 -- REFERENCES -- 5 High-Cost Case Management -- FOCUS OF HIGH-COST CASE MANAGEMENT -- ROLE OF THE PURCHASER -- HOW HIGH-COST CASE MANAGEMENT WORKS. 327 $aOperational 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 -- CONCLUSION -- REFERENCES -- 6 Conclusions and Recommendations -- CURRENT STATUS OF UTILIZATION MANAGEMENT -- HOW UTILIZATION MANAGEMENT IS EVOLVING -- Scope of Review -- Operational Efficiency -- Rationing -- ISSUES FOR THE FUTURE -- RECOMMENDATIONS FOR THE NEAR TERM -- Responsibilities of Employers and Purchasers -- Responsibilities of Utilization Management Organizations -- Responsibilities of Health Care Practitioners and Institutions -- Responsibilities of Patients -- RECOMMENDATIONS AND QUESTIONS FOR THE LONGER TERM -- Research on Effectiveness -- Practice Guidelines and Review Criteria -- Oversight of Utilization Management -- CONCLUSION -- 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. 327 $aLiability 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 -- Quality Assurance -- 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 -- Background -- Control Type -- Financial Incentives -- Design of Mis System -- Utilization Management -- Medical Director and Utilization Management Support Staff -- Case Study 2: Group-Model Hmo -- Background -- Control Type -- Financial Incentives -- Design of Mis System -- Utilization Management -- Medical Director and Utilization Management Support Staff -- Case Study 3: Carrier-Sponsored Hmo -- Background -- Control Type -- Financial Incentives -- Design of Mis System -- Utilization Management -- Medical Director and Utilization Management Support Staff -- Case Study 4: Carrier-Sponsored Hmo -- Background -- Control Type -- Financial Incentives -- Design of Mis System -- Utilization Management and Support Staff -- Medical Director and Utilization Management Support Staff -- Case Study 5: Physician-Sponsored Ipa -- Background -- Control Type. 327 $aFinancial Incentives -- Design of Mis System -- Utilization Management -- Ipa Management -- Notes and References -- Appendix C Utilization Management in Peer Review Organizations -- References -- 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. 330 $aUtilization 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. 606 $aCost control 606 $aHealth services administration$zUnited States 615 0$aCost control. 615 0$aHealth services administration 676 $a338.4/33621/0973 701 $aGray$b Bradford H.$f1942-$01626351 701 $aField$b Marilyn J$g(Marilyn Jane)$01610163 801 0$bMiAaPQ 801 1$bMiAaPQ 801 2$bMiAaPQ 906 $aBOOK 912 $a9910828354403321 996 $aControlling costs and changing patient care$93962307 997 $aUNINA