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Effectiveness and Outcomes in Health Care Proceedings of an Invitational Conference (1990) / Chapter Skim
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25 Use of Effectiveness Research in Managed Care Plans
Pages 218-223

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From page 218...
... Limitations of the effectiveness "strategy" in controlling health care costs. IMPORTANCE OF OUTCOMES RESEARCH It is important to emphasize that the group health insurance industry is under great pressure to control the rate of increase in health care costs.
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From page 219...
... The basic idea is that by carefully selecting cost-effective providers, giving them an appropriate level of risk sharing, and carefully monitoring utilization, health care costs can be controlled. Risk-sharing is an important element in this strategy because it helps focus the attention of providers on the efficient use of resources.
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From page 220...
... Clearly then, effectiveness research is an important component of the health insurance-managed care industry's strategy to control health care costs. CURRENT APPLICATIONS OF OUTCOMES RESEARCH CLINICAL PROTOCOLS AEtna has made a major investment in developing protocol-based utilization management programs, and several other insurers are moving in the same direction.
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From page 221...
... In addition to the traditional data from paid claims, many insurers are now collecting from utilization management programs clinically detailed information that can be linked to paid claims. A good example is the extensive clinical data obtained in AEtna's protocol-based reviews of selected procedures.
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From page 222...
... Because insurers operate many managed care plans in multiple locations, they offer an ideal natural laboratory for applications research. LIMITATIONS OF THE EFFECTIVENESS "STRATEGY" An underlying assumption of the effectiveness "strategy" is that with "hard" data on what medical treatments are cost-effective and with financial incentives and utilization management systems to influence provider practice behaviors, the rate of increase in health care costs can be substantially reduced.
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From page 223...
... I am convinced that managed care can work and that effeci~veness research will undoubtedly have a very positive long-term impact on improving health and making the delivery system more efficient. The health insurance industry is a strong supporter of this effort and is prepared to work with the research community to collect, analyze, and apply the results of effectiveness studies.
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Key Terms

  • utilization management
  • health insurance
  • care costs
  • care plans
  • insurance industry

  • health benefits
  • management programs
  • substantial amount
  • assessment programs
  • selected procedures

  • practice behaviors
  • clinical data
  • current applications
  • effectiveness studies
  • paid claims

  • ancillary services
  • care delivered
  • control costs
  • control health
  • university investigators

  • control strategies
  • strategies available
  • natural laboratory
  • practice styles
  • basic idea

  • community health
  • america suggest
  • financial risk
  • extensive clinical
  • covered benefits


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