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

• Pubblicazione: Washington, D.C., : National Academy Press, 1989
• Edizione: 1st ed.
• Descrizione fisica: 1 online resource (viii, 312 pages) : illustrations
• Disciplina: 338.4/33621/0973
• Soggetto topico: Cost control; Health services administration - United States
• Altri autori: GrayBradford H. <1942-> FieldMarilyn J (Marilyn Jane)
• Note generali: Bibliographic Level Mode of Issuance: Monograph
• Nota di bibliografia: Includes bibliographical references.
• Nota di contenuto: 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 -- 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. ; 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 -- 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. ; 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 -- 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. ; Financial 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.
• Sommario/riassunto: 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.
• Titolo autorizzato: Controlling costs and changing patient care
• ISBN: 1-280-21445-7; 9786610214457; 0-309-54309-6; 0-585-14457-5
• Formato: Materiale a stampa
• Livello bibliografico: Monografia
• Lingua di pubblicazione: Inglese
• Record Nr.: 9910828354403321
• Lo trovi qui: Univ. Federico II