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Appendix D
Summary of Public Hearings*

The Institute of Medicine Committee on Utilization Management by Third Parties held a public hearing on June 6, 1988, at the National Academy of Sciences building in Washington, D.C. Speakers from 27 organizations made presentations to the committee. A question and answer session followed each panel of three speakers. Eight groups submitted written testimony without any oral presentation.

Each of the organizations represented fell into one of five categories or interest groups (Table D-1 lists the organizations by category):

• Practitioners and Organized Medicine

• Health Care Institutions, Associations, and Suppliers

• Patients, Consumers, and Public Health Organizations

• Insurers and Utilization Management Firms

• Trade Associations and Other Organizations

The testimony reflected diverse sets of interests and perspectives on utilization management. There were differences of opinion over the appropriate role of the physician (and/or medical profession) in utilization management; the validity of the criteria currently being used; the impact of various approaches on cost, quality, and administration of services; criticisms or shortcomings of utilization management; and suggestions about what is needed for the future.

* This summary was prepared by Eileen Connor.



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Page 250 Appendix D Summary of Public Hearings* The Institute of Medicine Committee on Utilization Management by Third Parties held a public hearing on June 6, 1988, at the National Academy of Sciences building in Washington, D.C. Speakers from 27 organizations made presentations to the committee. A question and answer session followed each panel of three speakers. Eight groups submitted written testimony without any oral presentation. Each of the organizations represented fell into one of five categories or interest groups (Table D-1 lists the organizations by category): • Practitioners and Organized Medicine • Health Care Institutions, Associations, and Suppliers • Patients, Consumers, and Public Health Organizations • Insurers and Utilization Management Firms • Trade Associations and Other Organizations The testimony reflected diverse sets of interests and perspectives on utilization management. There were differences of opinion over the appropriate role of the physician (and/or medical profession) in utilization management; the validity of the criteria currently being used; the impact of various approaches on cost, quality, and administration of services; criticisms or shortcomings of utilization management; and suggestions about what is needed for the future. * This summary was prepared by Eileen Connor.

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Page 251 TABLE D-1 Organizations Presenting Testimony at the Public Hearing on Utilization Management by Third Parties Practitioners and Organized Medicine   American Academy of Child & Adolescent Psychiatry   American Academy of Otolaryngology   American College of Physicians   American College of Utilization Review Physicians   American Dental Association   American Medical Association   American Psychological Association   American Rheumatism Association   Coalition to Preserve Quality (written only) Health Care Institutions, Associations, and Suppliers   American Hospital Association   American Pharmaceutical Association (written only)   Hospital Association of Pennsylvania (written only)   National Association of Ambulatory Care   National Association for Private Psychiatric Hospitals   Mayo Clinic (written only) Patient, Consumer, and Public Health Organizations   American Public Health Association   National Health Law Program   Public Citizen-Health Research Group Insurers and Utilization Management Firms   ALTA Health Strategies, Inc.   Blue Shield of California (written only)   Celtic Life Insurance   Health Care COMPARE   Health Data Institute   Health Management Strategies International, Inc.   Iowa Foundation for Medical Care   Quality Standards in Medicine, Inc. (written only)   U.S. Administrators Trade Associations and Other Organizations   American Association of Preferred Provider Organizations   Blue Cross and Blue Shield Association   Group Health Association of America   Healthcare Financial Management Association (written only)   Health Insurance Association of America (written only)   InterQual   Joint Commission on Accreditation of Health Care Organizations   National Association of Quality Assurance Professionals Despite the differences of opinion, however, there was considerable agreement on the following: 1. Utilization management is dynamic; it is evolving; studying utilization management now is like trying to focus on a moving target. 2. There is a proliferation of external review entities in the marketplace with different criteria and a variety of approaches to managing utilization. 3. There are variations in medical practice. 4. Criteria for appropriate medical care are imperfect.

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Page 252 5. Resources are limited (There is disagreement as to how limited, that is, how much the United States is willing or able to devote to health.) 6. Utilization management highlights the quality and cost debate in health care. 7. There are potential dangers in utilization management by third parties. 8. Utilization management does not seem to influence physician practices. (There is disagreement on how, why, and if it is good or bad.) 9. Utilization management needs physician involvement. (There is disagreement on the type and amount of physician involvement.) 10. Current utilization management programs do little or nothing in the areas of outpatient and office practice and/or monitoring for underservice.