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From page 301... ... , 95-96, 131 health planning efforts, 36 high-cost case management by, 119, 129, 131 integrated servicef~nsurance products, 50 losses, 2 managed fee-for-se/vice days under, 95 of Massachusetts, 95 of Minnesota, 45 of North Carolina, 93 of Northeast Ohio, 36 operational problems in, Z22 of Pennsylvania, 43 small-area study by, 45, 69 Read the entire page →
From page 302... ... 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 lay, 61, 6~69, 25~259, 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, 81~2 defined, 18, 170 electiveness 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 INDEX Coronary angiographies, 46 Coronary artery bypass surgeries, 46, 147 Cost management/containment strategies basic elements of, 32-33 benefit plan design, 20, 3~35, 214 control of provider payments, 21, 35 early efforts by third parties, 32-38 electiveness of, 24 25 employer interest in, 40~3 federal government initiatives, 38~0 financial incentives to providers, 2~21 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, 4~47 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, 4708 number of providers and, 24, 35-36, 43 prior review and, 92, 10~101, 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) Read the entire page →
From page 303... ... 3 review-versus nonreview groups, 96, 100 see also Studies and surveys of utilization management Expenditures for health care by business/private industry, 15, 16 by health plan members for high-cost illnesses/injuries, 12~121 hospital care, 31 by major sources of funds, 31 number of physicians and, 24 personal health care, 31 physician services, 31 prior review and, 96 total, trends in, 1~15 Experimental Medical Care Review Organizations, 39 F Federal government health care cost~ontainment initiatives. 3800 see also Medicare; Peer review organizations Fee-for-service highest case management and, 129 managed programs for, 50 and volume of physician services, 44 Foundations for Medical Care, 30, 35, 37, G General Motors, cost-containment reports, 30, 41~2 Greater Phoenix Affordable Health Care Foundation, 42 Group Health Association of America, 31 Group Health Association of Washington, D.C., 3~31, 35 H Health benefits, see Health insurance plans Health Care Financing Administration, 121 n.1, 154 Health education, employer support for, 41 Health Insurance Association of America, 107, 148, 154 Health insurance industry growth of, 27-32 integrated senriceplnsurance products, 50 Read the entire page →
From page 304... ... 304 losses, 2, IS, 60 premium setting, 100-101 utilization management by, 60 withdrawals from group insurance market, IS Health Insurance Plan of Greater New York, 35 Health insurance plans coinsurance rates, 104 community rating, 33 cost controls in, 20, 3035 cost sharing in, 96, 109, llS, lS1 coverage of alternatives to hospitalization, 41 decision-making process, 212 deductibles, 104 defined contribution programs, 110 design of benefits, 20, 3035, 94, llS, 148, 151, 214 duplicate coverage, 114 enrollee/patient navigation of, 103-104 enrollment trends, 3~32 exceptions to limitations in, 19-20, 122, 14~141, 173 expenditures by businesses, lolls experience rating, 33 HMO underwriting practices, 214 individually purchased, 34, 153 information on prior review policies in, 79 limits on coverage, 141 n.8, 173 premium increases, IS prior review integrated with, 66, 6~69 refusal to certify, 4 risk pool management for, 33-34 second -surgical-opinion provisions, 37 for self-employed people, 34 sources of, 32 triple option benefit package, S1 see also Costs of health care; Uninsured people ~ Health maintenance organizations (HMOs3 antitrust liability, 184 benefit design, 214 carrier-sponsored, 235-240 case studies, 213, 229-243 claims processing, 22~221 clinical protocols/guidelines, 215, 218 congressional support for, 47 data analysis lay, 215-216, 219 data integrity in, 221-222 defined, 206 INDEX delivery of health services, 21S-219 employer support for, 41 enrollee understanding of benefit restrictions in, 205-206 enrollment criteria, 214 enrollment information, 114 enrollments, 50, 214, 219, 220 factors affecting performance, 209-213 federalb qualified, 214, 219 goals of, 210-211 group-model, 207, 217, 23~235 growth in, SO high cost case management by, 129, 218 hospital-sponsored IPA, 230-232 hospital use in, 44, 177 integrated service/insurance products, SO losses, 2, 209 management information systems, 22~221, 222, 223, 231, 234, 236-237, 23~239, 241-242 market effects of and on, 209-210 medical director's role, 222, 232, 237, 240 medical necessity determinations, 173 network model, 207 open-ended, S1 operational problems, 220-222 operations, 211-213 organizational structure, 65, 207-209, 21~211, 216 patient flow procedures, 215, 218 patient payment obligations, l9S peer review in, 216, 219, 222 physician contracting arrangements with, 211-212, 217 physician incentives used by, 47, 211, 216, 22~227, 230 231, 23~234, 236, 238, 241 physician selection, 215 physician-sponsored IPA, 24~243 policy and research issues, 227-229 quality assurance in, 206, 216, 21~220, 222-224 quality of care in, SO, 205, 210, 211, 223 regulation of, 50, 207, 210, 219-220, 223 stab model, 207, 215 types of, 207 underwriting benefits, 214 utilization management approaches, 6, 66, 214-222, 229, 231-232, 234-235, 237, 239-240, 242 Read the entire page →
From page 305... ... financial incentives in, 224 225, 226, 241 management information system in, 241 model for, 35, 37 operational responsibilities of, 212-213 peer review in, 216, 222 physician contracting arrangements with, 217 physician selection by, 215, 218-219 physician-sponsored, 24~243 quality assurance in, 216, 218 utilization management procedures, 51, 59, 217-218, 242 Information resources, on cost and use of health services, 47~8 International Medical Centers Inc., 205 Intracorp, 131 Read the entire page →
From page 306... ... Califomia, 88, 109, 140, 170, 171-172, 170176, 178-179, 186, 188, 191, 192 Liability antitrust, 18~185 of attending physician, 88, 105, 19(~192 bad faith in insurance and, 175, 180-181, 187, 189 for breach of contract, 175, 179-180, 189 causation and, 172, 174, 17~179, 180, 181, 187 INDEX of consultants and employees, 185-186 for defamation, 183-184 direct, 189 and duty of care, 175-177, 180 of employer/payer, 109, 18~190 fiduciary relationship and, 181, 187-188 indemnity, 190 infliction of emotional distress, 182 and informed consent, 192 for interference with contractual advantage, 18~184 negligence, 175-179, 180, 181, 189 products, 18~183 of review organization, 4, 78, 83, 88, 89, 140, 145, 173-188, 280285 and standard of care, 176-178, 185 vicarious, 189-190 and warranty theories, 182 Louisiana, regulation of utilization review organizations, 186 M Maine, regulation of utilization review organizations, 186-187 Mammography screening, 23 Maryland, regulation of utilization review organizations, 186 Massachusetts Business Roundtable, 42 Mayo Clinic, utilization review plans, 59, 107 McCarthy, Eugene, 37 Medicaid programs cost-containment strategies, 38 evaluation of cost-containment strategies, 96 geographic data integration on, 69 liability for cost-containment mechanisms, 88, 171 second-opinion programs for, 39 Medical malpractice, 41, 105, 159, 191; see also Liability Medical organizations, see utdivid~al Corps Medical practice employer influence on standards for, 109 guidelines, 1~11, 23, 49, 107, 147, 159-160, 215 medical necessity concept, 171, 17~173 reasons for changes in patterns of, 136 137 variations in physician styles of, 46 Read the entire page →
From page 307... ... INDEX Medical services/procedures criteria for determining necessity of a procedure, 45, 83 expenditures for, relative to number of physicians, 24 fee-for-service payment rates and volume of, 44 geographic variation in patterns of, 41 45 inappropriate/unnecessary, 2, 15, 39, 44~6, 103, 194-195 methods for indentifying inappropriate use, 45 payment for unnecessary services, 194-195 rationing of, 24, 148 149 variations in utilization, 4~45 Medicare cost-containment strategies, 38, 43 costs of, 38 denials of payments, 77, 102 economic incentives to minimize days of care, 64 high-cost case management in, 138 preadmission review for, 14, 102 Recertification of beneficiaries, 59, 60 prospective payment system, 30, 40, 98, 101, 102, 106, 115, 116, 121 n.1 quality assurance program for, 116 quality of care in HMOs, 205 responsibility for reviewing care for beneficiaries, see Peer review organizations second-opinion programs for, 39 Methodological problems in studies of utilization management behavioral biases, 22 claims data, 111, 137, 158 confounding lay other interventions, 93-94, 96, 102, 115, 138 cost/price change considerations, 100 data availability and quality, 48 evaluator knowledge of data sources, 100 group data, 94, 111, 114, 137 high-cost case management, 13~138 measures of impacts and limitations, 22, 86, 11~113, 134, 135-136 medical care prices, llS noneconomic effects, 115-116 nonprogram variables, 100 program data, 100, 114 in review versus nonreview groups, 100 307 savings calculations, 11~115, 134-137 short time series, 100 Midwest Group on Health, 42 Muscular dystrophy, 121, 136 N National Conference on Medical Costs, 40 Nazemetz, Patricia M., 42 Nightingale, Florence, 36 n.5 Nurse reviewers/managers highest case management by, 128, 140 n.7 liability of, 177 monitoring of, 73 qualifications, 7~73, 140 n.7, 270277 responsibilities, 66, 70, 71-73, 77, 84, 85, 89, 10~104, 276-277 scope of assessments, 14~149 training, 73, 104 Nursing homes, prospective payment system and utilization of, 102 o Office of Personnel Management, 122 n.2 p Patients/enrollees case manager relationship with, 128-130 high-cost, types of, 121 legal issues for, 193-195 medical abandonment of, 192 payment obligations for unnecessary services, 194-lgS penalties for noncooperation in review, 1~19, 69, 88 responsibilities on utilization management, 9, 69-70, 108, 155-156 Peer review organizations (PROs) appeals processes, 85 case management by, 121 n.1 claims data tracking lay, 116 congressional support for, 47 demonstration project on small-area analyses for, 45 n.7 denials of Medicare payments, 77, 102 federal oversight of, 11-12, 65, 154 geographic data integration, 69 highest case management by, 131 liability of, 185 physician adviser role in, 74-75 Read the entire page →
From page 308... ... , 30 31, 35, 51 Preservice/preprocedure review, 18, 79 Prior review and actuarial estimates of savings, 101 anxiety and inconvenience caused fly, 4, 103, 146 appeals processes, 6, 7, 85 86, 107, 108, 149-150, 171, 172, 179, 183 before-and-after studies of, 91-93, 94 Comparative studies of, 9~96 Components of, 3, 18, 6~67, 83 Read the entire page →
From page 309... ... INDEX contingent nature of, 19 contractual descriptions of services, 282 283 criteria for assessment of care, 7 - , 79 85, 89, 15~160 definition of, 17-18, 170 employer/purchaser reactions to, 42, 108 110 enrollee/patient education on, 7, 10~104, 109 financial penalties for noncooperation in, 1~19, 104 focus of, 66, 89, 110 guidelines for conduct of, 108, 148 handling of attending physicians, 72, 74, 78 impact of programs, 91-116 initiation of, 42, 6070 and inpatient hospital utilization, 92, 93, 9~97, 110 integration with benefit plan administration, 66-69 liability-in, 180 limitations of data on, 114 measures of impact, 112-113 for Medicare recipients, 14 multivariate studies of, 96-98 numes' role in, 66, 71-73, 89 and outpatient/physician office services use, 92, 97 and patient costs, comfort, and convenience, 92,104, 109 physician adviser role in, 66, 72, 73-78, 83, 86, 89 and physician-hospital relations, 106 and physician-patient relationship, 105-106 and provider-purchaser relations, 106 108 and quality of care, 4, 7, 10Q 103, 110, 115-116, 146, 149 refusals to authorize services, 19 reporting and feedback mechanisms, 8~87 responsibility for obtaining, 108 retrospective denial of claims following, 19, 98, 106 spillover erects of, 98, 101, 110 targeting of, 108 timeliness in handling of requests, 107, 104 trends in use of, 14 309 weaknesses in evidence on, 90101, 145 see also Admission review; Continued-stay/concurrent review; Discharge planning; Preadmission review; Second-opinion programs Private employers attitudes on high-cost case management, 133-134 education of employees on utilization management requirements, 7, 103 104, 109, 151, 182 effects of prior review on, 108 110 expenditures for health benefits, 2 factors shaping decisions on prior review, 109-110 health care cost-containment initiatives, 4~43 with insured health benefit plans, 2; see also Health insurance plans liability for utilization review, 109, 188 190 population covered by health insurance plans through, 32 PRO review contracts with, 39 responsibilities in utilization management, 6-7, 69-70, 150-151 self-insurance by, 2, 41, 60, 61, 182, 189 share of spending for health services, 40 Professional Standards Review Organization (PSROs) , 39, 59, 60, 66, 79, 93 Proprietary information, and competition, 7-9, 286 287 Prospective Payment Assessment Commission, 102 Prospective reimbursement employer support for, 41 see also Medicare Prostatectomy, 46, 156 Provident Mutual, 15 Provider payments controls on, 35 Psychiatric cases health plan coverage for, 141 n.8, 149 highest case management for, 128, 138, 141 n.8 Q Quality assurance defined, 219 in highest case management, 140 in HMOs, 206, 216, 219-220, 222-224 Read the entire page →
From page 310... ... 310 monitoring performance of nurse-reviewem and physician-advisers, 73, 75, 77 operational problems impairing, Z~224 in utilization management, 6, 73, 75, 77, 140, 150 Quality of care guideline development for, 154 high-cost case management and, 133, 134 in HMOs, 205, 210, 211 physician incentive plans and, 205 prior review and, 4, 7, 10Q 103, 110, 115-116, 146 utilization management and, 4, 36 n.5, 46-47, 146, 154 R Rand Corporation, 46, 107 RCA Plan for Health, 95 Recommendations appeals of review decisions, 6, 149-150 disclosure criteria, 6, 7, 149, 160 employer/purchaser responsibilities, 6-7, 150-151 long-term, 9-12, 157-161 near-term, 6-9, 15~157 oversight of utilization management, 11-12, 16~161 patient responsibilities, 9, 156-157 practice guidelines, 1~11, 159-160 practitionersfinstitution responsibilities, 8, 155-156 quality assurance mechanisms, 6, 150 research on effectiveness, 6, 9-10, 149, 157-159 review critena, 6, 7, 9, 11, 149, 150160 utilization management organizations' responsibilities, 7~, 151-154 Research on appropriate care, 45 46, 48, 52, 83 Research on utilization management clinical, limits on, 158, 159 feedback and education strategies, 4-5, 147 impediments to, 10 programmatic, 15~159 recommended, 6, 9-10, 157-159 targets of, 89, 158 see also Evaluation of utilization management; Studies and surveys of utilization management INDEX Research on variations in utilization management, 41 45, 46, 48, 65 Retrospective utilization review advantages and disadvantages of, 20 appeals processes, 193 denial of claims following prior certification, 19, 98,106 of high-cost cases, 127 hospitalization criteria, 79~0 initial focus of, 35 litigation, 88, 17~171 by PROs, 69 by PSROs, 39, 69, 79~0 regulation, 39; see also Legal issues and litigation targeting problem provided, 69 Risk pools, management of, 3~34 Ross-Loos Medical Group, 30, 35 S Second-opinion programs impact of, 9~99 objectives of, 87 participation rates, 99 and patient anxiety, 103 penalties for nonparticipation in, 99 prior review combined with, 83, 99 procedures subject to, 68, 79, 87 requirements of, 87 88 resistance from medical community, 37 screening referrals for, 18 types of, 87 Self-insurance advantages of, 41 claims processing, 61 and insurance industry structural changes, 60 61 and liability, 182, 189 monthly costs for family coverage, 41 Service Employees International Union, 95, 13~131 Services Interaction Targets for Opportunities program, 120 Social/Health Maintenance Organization demonstration projects, 120 Social Security Amendments of 1972, 39 Spinal injury cases, 131, 138 Store Workers Health and Welfare Fund, 37 Studies and surveys of utilization management before-and-after, 91-93, 94 Read the entire page →
From page 311... ... INDEX case studies of HMOs, 229-243 case studies of PSROs, 93 comparative, 93-96, 145 control for systemwide influences, 95 Health Interview Survey, 94 Hospital Discharge Survey, 94 multivariate, 96-98, 145 small-area, 214 45 see also Methodological problems in studies of utilization management T Third-party financing of health care cost management efforts, 32-38 defined, 28 n.1 growth of, 27-32 see also Health insurance industry Tonsillectomy and adenoidectomy, 68, 76, 80, 82, 104 lLansamerica Occidental, 15 mpanotomy tube insertion, 83 U Uninsured people access to health care, 24 number of, 31-32 United Mine Workers Union, 37 Utilization management administrative burdens on providers, 4, 5, 7, 107, 144, 146, 147, 154 assessment strategies, 4~49, 66; see also Criteria for assessment of care; Methodological problems in studies of utilization management case studies, 229-243 claims administration integrated with, 61, 6~69 common elements of programs, 66 computerization of, 5, 70, 71, 73, 139, 145, 148, 18~183, 221 concerns about, 5-6, 149-150 definition of, 2-3, 17 education strategies for, 4~49 effects on health care use and cost, 1-2, ~4, 14, 52, 145-146, 220 employer initiatives, 40-43 evolution of, 147-149 federal government initiatives, 38~0 focus of, 4, 145, 169 growth of, 2, 14, 105, 143, 169 guidelines for conduct of, 108, 154 311 in health maintenance organizations, 205-243 industry structure and process, 5~90 information resources for, 47~8 and inpatient days, 95-96 operational efficiency, 148 operational problems impairing, 220-222 origins of, 21-52 in peer review organizations, 246 249 policy and research issues, 227-229 public hearings on, 25~252 quality assurance in, 6, 7, 43, 150 and quality of care, 4, 7, 36 n.5, 46~7, 102-103, 110, 146, 154 and rationing of medical services, 14~149 recommendations on, 5-12, 143-162 refusals to certify beneSts, 4 regulation/oversight of, 4, 11-12, 73, 89, 144, 150, 16~161 research influences on, 5, 43~6, 145, 147 scope of review, 66, 147 spillover effects of, 98, 101, 110 standardization of processes, 107 status of, 144-146 and surgical days/rates, 95-96, 97 third-party efforts, 3~38 see also Cost management/containment strategies; Prior review; Second-opinion programs Utilization management organizations agreements with clients, 282-287 analysis and reporting of utilization and cost data, 109 antitrust liabilities, 184 185 breach of contract By, 179-180 constraints on growth of, 5 consultant/employee liability, 185-186 contact with patients or physicians, 66 defamation by, and interference with contractual advantage, 183-184 duty of care, 175-176 effects of organizational differences in, 65 employer/purchaser investigation of, 15~153 financial incentives offered By, 50, 73 freestanding services, 51, 62, 63, 123 124, 145 geographic data integration in, 69 growth of, 50, 59-61 Read the entire page →
From page 312... ... 312 handling of attending physician, 72, 74, 78 improvement of provider relations with, 153-154 independent review organization, 62, 17~174, 17~180, 185, 187-188, 259-260, 266 268 infliction of emotional distress, 182 insurance bad faith liability, 18~181 insurance company subsidiaries, 62, 262-264 insurer-based service, 63 insurer- or broker-based service, 6~64 IPA model HMO, 62, 271-272 largest firms, 60 liability of, 4, 5, 78, 83, 88, 145, 173-188, 28~285 management priorities, 5 moral obligations of, 153 negligence lay, 175-179 not-for-profit PRO, 269-270 peer review organizations, 60, 66, 272-274 procedural safeguards for, 17~177 proprietary information and competition among, 7-8, 286 287 provider-based, 64 quality assurance mechanisms, 6, 62 regulation of, 50, 65, 75, 88, 94, 145 responsibilities of, 7-9, 151-154 reviews/audits of, 62 role specification in contracts, 283-284 Zenith 122 selection of, 6-7 site visit summaries, 62, 253-281 small, private, for-profit, 25~256 staff model HMO, 62, 268 269 staffing and performance criteria, 71-78, 276-281, 285-286; see also Nurse -reviewers managers; Physicians, advisers state regulation of, 18~187 subsidiary of third-party payer, 256-257, 264 266 telephone call handling, 7~71 third-party claims administrators, 61, 258-259, 261-262 triple option benefit package, 51 types and numbers of, 49-51, 59~2 variability in programs, 4, 65, 89, 111 145 volume of business in, 275 Utilization review INDEX admission review, 18, 37 ambulatory care review, 37 computerized claims screening, 37 continued-stay/concurrent review, 3, 18, 37, 39, 48, 65, 66, 81~, 93, 98 effectiveness of, 3~39 historical background, 3038 model treatment profiles, 37 preadmission, 3, 18, 37, 39, 41, 65, 66, 87, 88, 93, 98 as a prerequisite to Medicare participation, 38 retroactive, 41 timeliness in handling of requests/appeals, 107, 108, 186 187, 193-194 V Value Health Sciences, 107 n.3 W Washington Business Group on Health, 30, 42 Wellness programs, 45 Wennberg, John, 30, 44 Workers compensation, highest case management in, 131 z Read the entire page →

From page 301...

... , 95-96, 131 health planning efforts, 36 high-cost case management by, 119, 129, 131 integrated servicef~nsurance products, 50 losses, 2 managed fee-for-se/vice days under, 95 of Massachusetts, 95 of Minnesota, 45 of North Carolina, 93 of Northeast Ohio, 36 operational problems in, Z22 of Pennsylvania, 43 small-area study by, 45, 69

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From page 302...

... 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 lay, 61, 6~69, 25~259, 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, 81~2 defined, 18, 170 electiveness 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 INDEX Coronary angiographies, 46 Coronary artery bypass surgeries, 46, 147 Cost management/containment strategies basic elements of, 32-33 benefit plan design, 20, 3~35, 214 control of provider payments, 21, 35 early efforts by third parties, 32-38 electiveness of, 24 25 employer interest in, 40~3 federal government initiatives, 38~0 financial incentives to providers, 2~21 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, 4~47 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, 4708 number of providers and, 24, 35-36, 43 prior review and, 92, 10~101, 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)

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From page 303...

... 3 review-versus nonreview groups, 96, 100 see also Studies and surveys of utilization management Expenditures for health care by business/private industry, 15, 16 by health plan members for high-cost illnesses/injuries, 12~121 hospital care, 31 by major sources of funds, 31 number of physicians and, 24 personal health care, 31 physician services, 31 prior review and, 96 total, trends in, 1~15 Experimental Medical Care Review Organizations, 39 F Federal government health care cost~ontainment initiatives. 3800 see also Medicare; Peer review organizations Fee-for-service highest case management and, 129 managed programs for, 50 and volume of physician services, 44 Foundations for Medical Care, 30, 35, 37, G General Motors, cost-containment reports, 30, 41~2 Greater Phoenix Affordable Health Care Foundation, 42 Group Health Association of America, 31 Group Health Association of Washington, D.C., 3~31, 35 H Health benefits, see Health insurance plans Health Care Financing Administration, 121 n.1, 154 Health education, employer support for, 41 Health Insurance Association of America, 107, 148, 154 Health insurance industry growth of, 27-32 integrated senriceplnsurance products, 50

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From page 304...

... 304 losses, 2, IS, 60 premium setting, 100-101 utilization management by, 60 withdrawals from group insurance market, IS Health Insurance Plan of Greater New York, 35 Health insurance plans coinsurance rates, 104 community rating, 33 cost controls in, 20, 3035 cost sharing in, 96, 109, llS, lS1 coverage of alternatives to hospitalization, 41 decision-making process, 212 deductibles, 104 defined contribution programs, 110 design of benefits, 20, 3035, 94, llS, 148, 151, 214 duplicate coverage, 114 enrollee/patient navigation of, 103-104 enrollment trends, 3~32 exceptions to limitations in, 19-20, 122, 14~141, 173 expenditures by businesses, lolls experience rating, 33 HMO underwriting practices, 214 individually purchased, 34, 153 information on prior review policies in, 79 limits on coverage, 141 n.8, 173 premium increases, IS prior review integrated with, 66, 6~69 refusal to certify, 4 risk pool management for, 33-34 second -surgical-opinion provisions, 37 for self-employed people, 34 sources of, 32 triple option benefit package, S1 see also Costs of health care; Uninsured people ~ Health maintenance organizations (HMOs3 antitrust liability, 184 benefit design, 214 carrier-sponsored, 235-240 case studies, 213, 229-243 claims processing, 22~221 clinical protocols/guidelines, 215, 218 congressional support for, 47 data analysis lay, 215-216, 219 data integrity in, 221-222 defined, 206 INDEX delivery of health services, 21S-219 employer support for, 41 enrollee understanding of benefit restrictions in, 205-206 enrollment criteria, 214 enrollment information, 114 enrollments, 50, 214, 219, 220 factors affecting performance, 209-213 federalb qualified, 214, 219 goals of, 210-211 group-model, 207, 217, 23~235 growth in, SO high cost case management by, 129, 218 hospital-sponsored IPA, 230-232 hospital use in, 44, 177 integrated service/insurance products, SO losses, 2, 209 management information systems, 22~221, 222, 223, 231, 234, 236-237, 23~239, 241-242 market effects of and on, 209-210 medical director's role, 222, 232, 237, 240 medical necessity determinations, 173 network model, 207 open-ended, S1 operational problems, 220-222 operations, 211-213 organizational structure, 65, 207-209, 21~211, 216 patient flow procedures, 215, 218 patient payment obligations, l9S peer review in, 216, 219, 222 physician contracting arrangements with, 211-212, 217 physician incentives used by, 47, 211, 216, 22~227, 230 231, 23~234, 236, 238, 241 physician selection, 215 physician-sponsored IPA, 24~243 policy and research issues, 227-229 quality assurance in, 206, 216, 21~220, 222-224 quality of care in, SO, 205, 210, 211, 223 regulation of, 50, 207, 210, 219-220, 223 stab model, 207, 215 types of, 207 underwriting benefits, 214 utilization management approaches, 6, 66, 214-222, 229, 231-232, 234-235, 237, 239-240, 242

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From page 305...

... financial incentives in, 224 225, 226, 241 management information system in, 241 model for, 35, 37 operational responsibilities of, 212-213 peer review in, 216, 222 physician contracting arrangements with, 217 physician selection by, 215, 218-219 physician-sponsored, 24~243 quality assurance in, 216, 218 utilization management procedures, 51, 59, 217-218, 242 Information resources, on cost and use of health services, 47~8 International Medical Centers Inc., 205 Intracorp, 131

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From page 306...

... Califomia, 88, 109, 140, 170, 171-172, 170176, 178-179, 186, 188, 191, 192 Liability antitrust, 18~185 of attending physician, 88, 105, 19(~192 bad faith in insurance and, 175, 180-181, 187, 189 for breach of contract, 175, 179-180, 189 causation and, 172, 174, 17~179, 180, 181, 187 INDEX of consultants and employees, 185-186 for defamation, 183-184 direct, 189 and duty of care, 175-177, 180 of employer/payer, 109, 18~190 fiduciary relationship and, 181, 187-188 indemnity, 190 infliction of emotional distress, 182 and informed consent, 192 for interference with contractual advantage, 18~184 negligence, 175-179, 180, 181, 189 products, 18~183 of review organization, 4, 78, 83, 88, 89, 140, 145, 173-188, 280285 and standard of care, 176-178, 185 vicarious, 189-190 and warranty theories, 182 Louisiana, regulation of utilization review organizations, 186 M Maine, regulation of utilization review organizations, 186-187 Mammography screening, 23 Maryland, regulation of utilization review organizations, 186 Massachusetts Business Roundtable, 42 Mayo Clinic, utilization review plans, 59, 107 McCarthy, Eugene, 37 Medicaid programs cost-containment strategies, 38 evaluation of cost-containment strategies, 96 geographic data integration on, 69 liability for cost-containment mechanisms, 88, 171 second-opinion programs for, 39 Medical malpractice, 41, 105, 159, 191; see also Liability Medical organizations, see utdivid~al Corps Medical practice employer influence on standards for, 109 guidelines, 1~11, 23, 49, 107, 147, 159-160, 215 medical necessity concept, 171, 17~173 reasons for changes in patterns of, 136 137 variations in physician styles of, 46

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From page 307...

... INDEX Medical services/procedures criteria for determining necessity of a procedure, 45, 83 expenditures for, relative to number of physicians, 24 fee-for-service payment rates and volume of, 44 geographic variation in patterns of, 41 45 inappropriate/unnecessary, 2, 15, 39, 44~6, 103, 194-195 methods for indentifying inappropriate use, 45 payment for unnecessary services, 194-195 rationing of, 24, 148 149 variations in utilization, 4~45 Medicare cost-containment strategies, 38, 43 costs of, 38 denials of payments, 77, 102 economic incentives to minimize days of care, 64 high-cost case management in, 138 preadmission review for, 14, 102 Recertification of beneficiaries, 59, 60 prospective payment system, 30, 40, 98, 101, 102, 106, 115, 116, 121 n.1 quality assurance program for, 116 quality of care in HMOs, 205 responsibility for reviewing care for beneficiaries, see Peer review organizations second-opinion programs for, 39 Methodological problems in studies of utilization management behavioral biases, 22 claims data, 111, 137, 158 confounding lay other interventions, 93-94, 96, 102, 115, 138 cost/price change considerations, 100 data availability and quality, 48 evaluator knowledge of data sources, 100 group data, 94, 111, 114, 137 high-cost case management, 13~138 measures of impacts and limitations, 22, 86, 11~113, 134, 135-136 medical care prices, llS noneconomic effects, 115-116 nonprogram variables, 100 program data, 100, 114 in review versus nonreview groups, 100 307 savings calculations, 11~115, 134-137 short time series, 100 Midwest Group on Health, 42 Muscular dystrophy, 121, 136 N National Conference on Medical Costs, 40 Nazemetz, Patricia M., 42 Nightingale, Florence, 36 n.5 Nurse reviewers/managers highest case management by, 128, 140 n.7 liability of, 177 monitoring of, 73 qualifications, 7~73, 140 n.7, 270277 responsibilities, 66, 70, 71-73, 77, 84, 85, 89, 10~104, 276-277 scope of assessments, 14~149 training, 73, 104 Nursing homes, prospective payment system and utilization of, 102 o Office of Personnel Management, 122 n.2 p Patients/enrollees case manager relationship with, 128-130 high-cost, types of, 121 legal issues for, 193-195 medical abandonment of, 192 payment obligations for unnecessary services, 194-lgS penalties for noncooperation in review, 1~19, 69, 88 responsibilities on utilization management, 9, 69-70, 108, 155-156 Peer review organizations (PROs) appeals processes, 85 case management by, 121 n.1 claims data tracking lay, 116 congressional support for, 47 demonstration project on small-area analyses for, 45 n.7 denials of Medicare payments, 77, 102 federal oversight of, 11-12, 65, 154 geographic data integration, 69 highest case management by, 131 liability of, 185 physician adviser role in, 74-75

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From page 308...

... , 30 31, 35, 51 Preservice/preprocedure review, 18, 79 Prior review and actuarial estimates of savings, 101 anxiety and inconvenience caused fly, 4, 103, 146 appeals processes, 6, 7, 85 86, 107, 108, 149-150, 171, 172, 179, 183 before-and-after studies of, 91-93, 94 Comparative studies of, 9~96 Components of, 3, 18, 6~67, 83

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From page 309...

... INDEX contingent nature of, 19 contractual descriptions of services, 282 283 criteria for assessment of care, 7 - , 79 85, 89, 15~160 definition of, 17-18, 170 employer/purchaser reactions to, 42, 108 110 enrollee/patient education on, 7, 10~104, 109 financial penalties for noncooperation in, 1~19, 104 focus of, 66, 89, 110 guidelines for conduct of, 108, 148 handling of attending physicians, 72, 74, 78 impact of programs, 91-116 initiation of, 42, 6070 and inpatient hospital utilization, 92, 93, 9~97, 110 integration with benefit plan administration, 66-69 liability-in, 180 limitations of data on, 114 measures of impact, 112-113 for Medicare recipients, 14 multivariate studies of, 96-98 numes' role in, 66, 71-73, 89 and outpatient/physician office services use, 92, 97 and patient costs, comfort, and convenience, 92,104, 109 physician adviser role in, 66, 72, 73-78, 83, 86, 89 and physician-hospital relations, 106 and physician-patient relationship, 105-106 and provider-purchaser relations, 106 108 and quality of care, 4, 7, 10Q 103, 110, 115-116, 146, 149 refusals to authorize services, 19 reporting and feedback mechanisms, 8~87 responsibility for obtaining, 108 retrospective denial of claims following, 19, 98, 106 spillover erects of, 98, 101, 110 targeting of, 108 timeliness in handling of requests, 107, 104 trends in use of, 14 309 weaknesses in evidence on, 90101, 145 see also Admission review; Continued-stay/concurrent review; Discharge planning; Preadmission review; Second-opinion programs Private employers attitudes on high-cost case management, 133-134 education of employees on utilization management requirements, 7, 103 104, 109, 151, 182 effects of prior review on, 108 110 expenditures for health benefits, 2 factors shaping decisions on prior review, 109-110 health care cost-containment initiatives, 4~43 with insured health benefit plans, 2; see also Health insurance plans liability for utilization review, 109, 188 190 population covered by health insurance plans through, 32 PRO review contracts with, 39 responsibilities in utilization management, 6-7, 69-70, 150-151 self-insurance by, 2, 41, 60, 61, 182, 189 share of spending for health services, 40 Professional Standards Review Organization (PSROs) , 39, 59, 60, 66, 79, 93 Proprietary information, and competition, 7-9, 286 287 Prospective Payment Assessment Commission, 102 Prospective reimbursement employer support for, 41 see also Medicare Prostatectomy, 46, 156 Provident Mutual, 15 Provider payments controls on, 35 Psychiatric cases health plan coverage for, 141 n.8, 149 highest case management for, 128, 138, 141 n.8 Q Quality assurance defined, 219 in highest case management, 140 in HMOs, 206, 216, 219-220, 222-224

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From page 310...

... 310 monitoring performance of nurse-reviewem and physician-advisers, 73, 75, 77 operational problems impairing, Z~224 in utilization management, 6, 73, 75, 77, 140, 150 Quality of care guideline development for, 154 high-cost case management and, 133, 134 in HMOs, 205, 210, 211 physician incentive plans and, 205 prior review and, 4, 7, 10Q 103, 110, 115-116, 146 utilization management and, 4, 36 n.5, 46-47, 146, 154 R Rand Corporation, 46, 107 RCA Plan for Health, 95 Recommendations appeals of review decisions, 6, 149-150 disclosure criteria, 6, 7, 149, 160 employer/purchaser responsibilities, 6-7, 150-151 long-term, 9-12, 157-161 near-term, 6-9, 15~157 oversight of utilization management, 11-12, 16~161 patient responsibilities, 9, 156-157 practice guidelines, 1~11, 159-160 practitionersfinstitution responsibilities, 8, 155-156 quality assurance mechanisms, 6, 150 research on effectiveness, 6, 9-10, 149, 157-159 review critena, 6, 7, 9, 11, 149, 150160 utilization management organizations' responsibilities, 7~, 151-154 Research on appropriate care, 45 46, 48, 52, 83 Research on utilization management clinical, limits on, 158, 159 feedback and education strategies, 4-5, 147 impediments to, 10 programmatic, 15~159 recommended, 6, 9-10, 157-159 targets of, 89, 158 see also Evaluation of utilization management; Studies and surveys of utilization management INDEX Research on variations in utilization management, 41 45, 46, 48, 65 Retrospective utilization review advantages and disadvantages of, 20 appeals processes, 193 denial of claims following prior certification, 19, 98,106 of high-cost cases, 127 hospitalization criteria, 79~0 initial focus of, 35 litigation, 88, 17~171 by PROs, 69 by PSROs, 39, 69, 79~0 regulation, 39; see also Legal issues and litigation targeting problem provided, 69 Risk pools, management of, 3~34 Ross-Loos Medical Group, 30, 35 S Second-opinion programs impact of, 9~99 objectives of, 87 participation rates, 99 and patient anxiety, 103 penalties for nonparticipation in, 99 prior review combined with, 83, 99 procedures subject to, 68, 79, 87 requirements of, 87 88 resistance from medical community, 37 screening referrals for, 18 types of, 87 Self-insurance advantages of, 41 claims processing, 61 and insurance industry structural changes, 60 61 and liability, 182, 189 monthly costs for family coverage, 41 Service Employees International Union, 95, 13~131 Services Interaction Targets for Opportunities program, 120 Social/Health Maintenance Organization demonstration projects, 120 Social Security Amendments of 1972, 39 Spinal injury cases, 131, 138 Store Workers Health and Welfare Fund, 37 Studies and surveys of utilization management before-and-after, 91-93, 94

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From page 311...

... INDEX case studies of HMOs, 229-243 case studies of PSROs, 93 comparative, 93-96, 145 control for systemwide influences, 95 Health Interview Survey, 94 Hospital Discharge Survey, 94 multivariate, 96-98, 145 small-area, 214 45 see also Methodological problems in studies of utilization management T Third-party financing of health care cost management efforts, 32-38 defined, 28 n.1 growth of, 27-32 see also Health insurance industry Tonsillectomy and adenoidectomy, 68, 76, 80, 82, 104 lLansamerica Occidental, 15 mpanotomy tube insertion, 83 U Uninsured people access to health care, 24 number of, 31-32 United Mine Workers Union, 37 Utilization management administrative burdens on providers, 4, 5, 7, 107, 144, 146, 147, 154 assessment strategies, 4~49, 66; see also Criteria for assessment of care; Methodological problems in studies of utilization management case studies, 229-243 claims administration integrated with, 61, 6~69 common elements of programs, 66 computerization of, 5, 70, 71, 73, 139, 145, 148, 18~183, 221 concerns about, 5-6, 149-150 definition of, 2-3, 17 education strategies for, 4~49 effects on health care use and cost, 1-2, ~4, 14, 52, 145-146, 220 employer initiatives, 40-43 evolution of, 147-149 federal government initiatives, 38~0 focus of, 4, 145, 169 growth of, 2, 14, 105, 143, 169 guidelines for conduct of, 108, 154 311 in health maintenance organizations, 205-243 industry structure and process, 5~90 information resources for, 47~8 and inpatient days, 95-96 operational efficiency, 148 operational problems impairing, 220-222 origins of, 21-52 in peer review organizations, 246 249 policy and research issues, 227-229 public hearings on, 25~252 quality assurance in, 6, 7, 43, 150 and quality of care, 4, 7, 36 n.5, 46~7, 102-103, 110, 146, 154 and rationing of medical services, 14~149 recommendations on, 5-12, 143-162 refusals to certify beneSts, 4 regulation/oversight of, 4, 11-12, 73, 89, 144, 150, 16~161 research influences on, 5, 43~6, 145, 147 scope of review, 66, 147 spillover effects of, 98, 101, 110 standardization of processes, 107 status of, 144-146 and surgical days/rates, 95-96, 97 third-party efforts, 3~38 see also Cost management/containment strategies; Prior review; Second-opinion programs Utilization management organizations agreements with clients, 282-287 analysis and reporting of utilization and cost data, 109 antitrust liabilities, 184 185 breach of contract By, 179-180 constraints on growth of, 5 consultant/employee liability, 185-186 contact with patients or physicians, 66 defamation by, and interference with contractual advantage, 183-184 duty of care, 175-176 effects of organizational differences in, 65 employer/purchaser investigation of, 15~153 financial incentives offered By, 50, 73 freestanding services, 51, 62, 63, 123 124, 145 geographic data integration in, 69 growth of, 50, 59-61

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From page 312...

... 312 handling of attending physician, 72, 74, 78 improvement of provider relations with, 153-154 independent review organization, 62, 17~174, 17~180, 185, 187-188, 259-260, 266 268 infliction of emotional distress, 182 insurance bad faith liability, 18~181 insurance company subsidiaries, 62, 262-264 insurer-based service, 63 insurer- or broker-based service, 6~64 IPA model HMO, 62, 271-272 largest firms, 60 liability of, 4, 5, 78, 83, 88, 145, 173-188, 28~285 management priorities, 5 moral obligations of, 153 negligence lay, 175-179 not-for-profit PRO, 269-270 peer review organizations, 60, 66, 272-274 procedural safeguards for, 17~177 proprietary information and competition among, 7-8, 286 287 provider-based, 64 quality assurance mechanisms, 6, 62 regulation of, 50, 65, 75, 88, 94, 145 responsibilities of, 7-9, 151-154 reviews/audits of, 62 role specification in contracts, 283-284 Zenith 122 selection of, 6-7 site visit summaries, 62, 253-281 small, private, for-profit, 25~256 staff model HMO, 62, 268 269 staffing and performance criteria, 71-78, 276-281, 285-286; see also Nurse -reviewers managers; Physicians, advisers state regulation of, 18~187 subsidiary of third-party payer, 256-257, 264 266 telephone call handling, 7~71 third-party claims administrators, 61, 258-259, 261-262 triple option benefit package, 51 types and numbers of, 49-51, 59~2 variability in programs, 4, 65, 89, 111 145 volume of business in, 275 Utilization review INDEX admission review, 18, 37 ambulatory care review, 37 computerized claims screening, 37 continued-stay/concurrent review, 3, 18, 37, 39, 48, 65, 66, 81~, 93, 98 effectiveness of, 3~39 historical background, 3038 model treatment profiles, 37 preadmission, 3, 18, 37, 39, 41, 65, 66, 87, 88, 93, 98 as a prerequisite to Medicare participation, 38 retroactive, 41 timeliness in handling of requests/appeals, 107, 108, 186 187, 193-194 V Value Health Sciences, 107 n.3 W Washington Business Group on Health, 30, 42 Wellness programs, 45 Wennberg, John, 30, 44 Workers compensation, highest case management in, 131 z

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Index Pages 301-312

Index
Pages 301-312