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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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| 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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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.
