Page 302

utilization review efforts/programs, 37, 59, 60-61, 93, 94, 98, 171

C

Cancer, 88, 121, 125

Cardiac pacemakers, 48, 83

Carotid endarterectomies, 46, 48, 83

Case management, see High-cost case management

Cataract surgery, 49, 158

Caterpillar, Inc., 131, 138

Ciba-Geigy, 122

Claims administrators

case management by, 123, 125

prior review by, 61, 68-69, 258-259, 261-262

Claims data

defects in cost and utilization data based on, 111, 158

high-cost case identification through, 127

HMO processing of, 220-221

quality-of-care information from, 115

Codman, Ernest, 36

Commercial health insurance companies, see Health insurance industry; Health insurance plans; and individual companies

Commission on Professional and Hospital Activities, 81-82

Committee on the Costs of Medical Care, 28

Concurrent review, see Continued-stay/concurrent review

Confidentiality of medical information

employer respect for, 7, 151

in high-cost case management, 132, 139 n.6

utilization management organization responsibility for, 7

Consumer price index, changes in, 15, 33

Continued-stay/concurrent review

appeals processes, 193

by Blue Cross plans, 37

criteria/standards for, 48, 81-82

defined, 18, 170

effectiveness of, 98

focus of, 120

high-cost case management and, 127, 139

liability for, 180

by PSROs, 39, 66

responsibility for, 66

variations in, 65, 66

Coronary angiographies, 46

Coronary artery bypass surgeries, 46, 147

Cost management/containment strategies

basic elements of, 32-33

benefit plan design, 20, 34-35, 214

control of provider payments, 21, 35

early efforts by third parties, 32-38

effectiveness of, 24-25

employer interest in, 40-43

federal government initiatives, 38-40

financial incentives to providers, 20-21

gatekeeping/triaging, 21

health planning, 35-36

inappropriate utilization as a target for, 44-46

physician education, 21

and quality assurance, 43

and quality of care, 46-47

risk pool management, 33-34

by small businesses, 42

utilization review, 36-38

Costs of health care

aging of population and, 24

causes of increases in, 23-24, 32, 115

and clinical judgments about value of treatments, 23

economic shocks and, 40

effects of utilization management on, 1-2, 3-4, 14, 52, 92, 95, 145-146

increases in, 2

information resources on, 47-48

number of providers and, 24, 35-36, 43

prior review and, 92, 100-101, 104

screening for untreatable diseases and, 24

third-party financing and, 28

trends in, 3-4

and U.S. competitiveness, 15

Council on Wage and Price Stability, 40

Criteria for assessment of care

adoption and modification of, 83-84, 177-178

appropriateness evaluation protocol (AEP), 80, 82

availability of, 5

competitiveness and, 22-23, 80, 154, 160

computerization of, 80, 107 n.3

diagnosis-specific, 48

differentiation by level of review, 84-85

exceptions to, 3, 72, 79, 173

of HMOs, 215

hospitalization, 79-82, 104



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